football medicine & performance - Spring 2022 - Issue 38 by Football Medicine & Performance Association

The official magazine of the Football Medicine & Performance Association

football medicine & performance

Issue 38 Spring 2022

In this issue COVID-19 Recovery in Athletes: The UK World Class Olympic and Paralympic Experience FMPA Virtual Conference 2022 Lessons

Learned From 10 Years of Periodic Health Evaluations uelling for the F Work Required in Professional Football: A Theoretical Model for Carbohydrate Periodisation

Legal • Education • Recruitment • Wellbeing

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MAD-UP

www.mad-up.com guy.moussi@mad-up.com

Who better than athletes, former professional footballers, to understand the importance of combining physical performance and maintaining a healthy metabolism? Who better to assess the risk of injury before, during and after exercise? Delis Ahou, Guy Moussi and Milos Dimitrijevic pushed their bodies to the limit on the field and in training; they know what it takes. These ex-footballers turned entrepreneurs are now paving the way for a safer and more personalised treatment of muscular issues, whatever the end goal.

In the same region where they first met and trained, this reunited team has developed a preventive and curative patented solution. Today, the team has grown with the investment of technical, medical and financial partners, and MAD-UP PRO is establishing itself in sports facilities, rehabilitation centres and physiotherapy practices all over the world.

MAD-UP AND ITS VALUES OF HIGH STANDARDS, PERFORMANCE AND EXCELLENCE ARE SPREADING FAST WITH GREAT PROSPECTS IN SIGHT.

CEO MESSAGE The legacy of the pandemic is an environment whereby people continue to keep a safe distance when passing each other in the street and where working in isolation at home prevails at a cost to work place interaction... But anyone who thinks that the rise of remote and hybrid work will be the downfall of teamwork is likely to be changing their tune by now. The truth is, teamwork is more important now than ever and nowhere is this more evident than in professional football. The recent premiership title and play off celebrations once again epitomised the `team` ethos behind success. Witness the inclusion of the medicine and performance team alongside the players, manager and coaching staff. Recognition indeed that it takes a united and cohesive `team` to bring that success. Teamwork skills are vital to be successful at work, regardless of your job title or discipline. Working well with colleagues, management and players will make your work environment enjoyable and help you complete tasks more quickly and efficiently. Clubs value employees who are team players as they contribute to the achievement of the organisation’s goals which ultimately translates to success on the pitch. The strength of the team is the individual member. The strength of each member is the team. I am very pleased to announce that the FMPA magazine is set to return to a printed format at the start of the 2022/23 season. This is a welcome return to `normality` and one that will once again become a staple of the medicine and performance arena. A digital version will also be available to members ensuring everyone has access to what is now a much respected, high calibre publication. And while I hesitate to tempt fate, we are already planning for a return to our annual Conference at the end of the 2022/23 season!

Eamonn S almon

Chief Executive Officer Football Medicine & Performance Association

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FROM THE EDITORS The 38th Edition of the Football Medicine and Performance editorial is upon us and we are proud to present you with this edition. With the season coming to an end, there is a greater focus on the preventive medicine during the off season. In this edition, Dustin Nabhan discusses this important topic and the role of the periodic health evaluation, a clinical process many of our practitioners will be undergoing in the coming months. We are also pleased to see restrictions easing off as life gradually returns to normal. As sport continues and we learn to manage our athletes during this time, Craig Ranson and James Hull’s article on COVID-19 clinical patterns, recovery time and prolonged impacts gives us an idea of what to expect next with our athlete population and how to optimise their care. This edition also marks the start of a partnership with the Aspetar Sports Medicine Journal, with content being shared between the two organisations. We feel this will help to enhance accessibility to evidence and high-quality content. To start this off, this edition features an important article on imaging in football medicine, which is an essential component in managing injured athletes and can be a complex one too, hence, this article will provide a basic introduction to the topic. Lastly, we would like to invite you all to our upcoming workshops. The 2022 FMPA Virtual Conference will take a critical look at three pillars producing effective performance. The people behind the scenes, the processes that they work by and because we are now in the generation of technology the products by which we use to continually improve our practise. The “Three P’s of Productive Performance” event will take place over 3 virtual workshops held over the second week of June and will provide around 11.5 hours of CPD for FMPA members. The event is FREE for FMPA Members and the content will be available to view for the whole of the 2022/2023 season. We hope you enjoy this edition and we will see you in the 2022 FMPA virtual conference!

Sean Carmody Dr Sean Carmody Editor, FMPA Magazine

Fadi Hassan Dr Fadi Hassan Editor, FMPA Magazine

Andrew Shafik Dr. Andrew Shafik Editor, FMPA Magazine

CONTENTS FEATURES

10 A Flock of Birds and the Complex Systems: Unfolding the Characteristics of Complex Systems in Sports Injury Rehabilitation Kate Yung 12 COVID-19 Recovery in Athletes: The UK World Class Olympic and Paralympic Experience Craig Ranson, James Hull

44 Personalising Female Footballer Hormone Health Dr Nicola Keay 46

uelling for the Work Required in F Professional Football: A Theoretical Model for Carbohydrate Periodisation Dr Liam Anderson

MPA Podcast with Anna West: F Importance of Sleep for Elite Footballers Elle Trezise

14 Interns, Placements & Morals: An Ethical Tale Ryan DeFreitas 20 FMPA Virtual Conference 2022 28 Imaging in Football Medicine Marcelo Bordalo, Eduardo Yamashiro, Maryam Rashed Alnaimi, Javier Arnaiz 38 Lessons Learned From 10 Years of Periodic Health Evaluations Dustin Nabhan, Carlos Jiménez

ABOUT

Football Medicine & Performance Association 43a Moor Lane, Clitheroe, Lancs, BB7 1BE 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 Commercial Manager Angela Walton angela.walton@fmpa.co.uk Marketing/Advertising Charles Whitney 0845 004 1040 Design Oporto Sports www.oportosports.com

Photography Alamy Images, FMPA, Unsplash Contributors Kate Yung, Craig Ranson, James Hull, Ryan DeFreitas, Marcelo Bordalo, Eduardo Yamashiro, Maryam Rashed Alnaimi, Javier Arnaiz, Dustin Nabhan, Carlos Jiménez, Dr Nicola Keay, Dr Liam Anderson, Elle Trezise

COVER IMAGE Newcastle United’s Jamal Lewis leaves the pitch with an injury during a Premier League match. Alamy Stock Photo

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

HARRY AND TONI TALK ABOUT THE IMPORTANCE OF MARGINAL GAINS IN ELITE FOOTBALL Toni Adds: “It’s super easy to travel with, it’s super easy to use and especially when the turnaround’s so quick in tournaments, it’s just going to add another string to your bow in recovering and making yourself feel better for the next big game. “I would 100% recommend it to other players of the sport, especially if you’re at the top of your game and you want to make a difference and get back onto the pitch quicker.”

When a player is at the top of their game the difference between them, and the next player in line, can be marginal. But sometimes it’s that one percent difference that counts. The team at ProMOTION spoke to two of their ambassadors, Manchester United’s Harry Maguire and Everton FC’s Toni Duggan about the theory of marginal gains in elite football, and how it’s applied as part of their regimes between games. “How you prepare for the next game and those marginal gains; every bit counts, especially in elite football,” says Toni. “At the top level, they’re the bits that can make the difference. As a professional at the top of your game, you have to look at things around the game that can help you improve and be ready for the next game.” Whether it’s focussing on nutrition, hydration, recovery (or all three) players know they need to prepare as much as they can between games to be ready for the next, as Toni explains. “When you’re at major tournaments, the turnaround in games is massive. You’re playing every two or three days in a European Championship or a World Cup - these are when the moments matter on the world stage, so you have to make sure that you’re getting everything right.”

And when a player doesn’t get it right or worse picks up an injury, Toni knows that the penalties can be high. “It’s competitive football and you’re at the top level, so there’s always someone wanting to step into your place and take your shirt and in a selfish way, you don’t want to give someone else that opportunity. “But it’s sport and it’s football and it’s a contact sport, and that’s what’s going to happen, so you need to make sure you do everything in your power that you can to be on the field as much as you can.” Both Toni and Harry use the ProMOTION EV1 as part of their regimes between matches and to help with their recovery from injuries. “Every little one percent that you can improve or help your body recover in time for the next game is important,” says Harry. “I use the EV1 on a daily basis, as much as I can, to give me that advantage. “It certainly worked for me as people thought I wouldn’t be back for the Euros or be able to play a part in it, but not only did I play a part in it but I managed to find my top form. The EV1 is a big help for me. It’s a big part of my career now.”

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The ProMOTION EV1 is an easy-to-use handheld device that applies targeted cryotherapy, heat therapy, contrast therapy and compression to support elite athletes to get back to fitness faster. It’s game-changing thermoelectric technology is fully backed by scientific research. For more information on the therapeutic benefits of the ProMOTION EV1 visit www.promotion.fitness A 20% discount is available to all FMPA Members on purchases of the ProMOTION EV1. Simply quote code FMPA20 at the checkout.

DON’T LET INJURIES THREATEN THE SUCCESS OF YOUR SEASON The ProMOTION EV1 supports athletes to get back to fitness, faster. It’s a versatile and easy to use handheld device that applies target cryotherapy, heat therapy, contrast therapy and compression.

“TO GET BACK FROM AN INJURY AS QUICK AS POSSIBLE IS A BIG PART OF BEING A FOOTBALLER” DA N B AC H M A N N WAT F O R D F. C .

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A FLOCK OF BIRDS AND THE COMPLEX SYSTEMS: UNFOLDING THE CHARACTERISTICS OF COMPLEX SYSTEMS IN SPORTS INJURY REHABILITATION FEATURE / KATE YUNG Introduction Since the development of the injury prevention model with the complex systems model [1], there has been increasing interest in the complex systems theory. Practitioners have been trying to understand how the model is relevant to their practice and how will it change their practice. The article aims to explain what the complex systems theory is and how it is relevant to the daily practice and operation in football.

Complex systems

Complicated & mul�factorial only.

What is the complex systems theory? • The complex systems theory, with more than 50 years of history [2], acknowledges the multifaceted nature of sports and seeks to understand the interactions among different factors and the outcomes of the systems [1, 3]. • Complex systems are dynamic, open systems [4]. They are characterised by non-linearity due to feedback loops and interaction among the factors. This means that outputs are not always proportional to the inputs, and a small adjustment may lead to a large change in the systems and vice versa [5].

Figure 1. A flock of birds and the complex systems

•

The flock emerged without any lead bird directing each bird’s action.

•

Multiple perspectives are required when viewing complex systems. The systems are three dimensional and interactions within the systems often occur at different scales and levels [7]. These include the environment, ecosystem and human activity (Figure 1).

• Complex systems are composed of a large number of interacting components which give rise to global behaviour and make up a system that exhibits novel characteristics [4]. • In the context of return to sport (RTS), these units could include age, wellness, biological healing of injured tissue, stress, external pressure and injury history. The units interact and define the space and dimension of the systems [6]. • This means that complex systems can not be understood by studying their parts. Instead, it may be better to be studied from multiple perspectives. • Examples of complex systems are flocks of birds, ecosystems and immune systems.

Complex systems in rehabilitation • Human systems, like a flock of birds, are also complex systems with distinctive characteristics. Using anterior cruciate ligament (ACL) rehabilitation as an example, we have described the characteristics of complex systems in our paper “Characteristics of Complex Systems in Sports Injury Rehabilitation: Examples and Implications for Practice”[8]. •

Complex systems explained with a flock of birds • All individual birds follow a simple rule: maintain proximity without bumping into each other. That results in emergent behaviour known as flocking (Figure 1).

In the context of RTS, the interacting factors could include age, wellness, biological healing of injured tissue, stress, external pressure and injury history. The factors will interact with the environment and other factors and consequently, different systems within systems emerge.

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•

These systems may be categorised based on their nature, for example, biomechanical, physiological and psychological.

•

They are also of multiple levels, namely individual, organisational and environmental. The individual level represents factors related to the individual athlete, from tissue healing to personal traits. The organisational level represents external factors related to the sporting club, organisation and support team, e.g., the coaching and medical team. The environmental level covers factors beyond the organisational level, such as the weather, playing schedule and competition level.

FAQ 1: I know rehabilitation is complex and multifactorial, why do I have to bother about complex systems? • The complex systems approach provides a theoretical framework for interpreting the patterns that emerged from biopsychosocial and other external factors. It is a tool for analyzing a problem more thoughtfully and efficiently.

football medicine & performance

•

In ACL rehabilitation, conducting independent clinical tests and functional assessments may provide useful information regarding the athletes’ physical and mental status. However, a complex systems approach facilitates a more complete picture of the problem and increased awareness of how different factors may interact. We encourage practitioners to consider multiple perspectives and come up with a solution or protocol that is broad and may address the root cause of a problem.

FAQ 2: If return to sport is so complex, is there anything we can do? • When assessing the test result for clinical and functional tests, practitioners should also be aware of the dynamic systems evolving around injury rehabilitation and endeavour to understand the full picture. •

•

There are at least two challenges in understanding and explaining the behaviour of systems: 1) The high degree of complexity and 2) it is nearly impossible to isolate a portion of the larger systems (i.e., isolation of the biological healing process from broader biopsychosocial factors). We may have to rely on computerbased decision support systems that have the capacity of incorporating features of complex systems in their design and utility. For example, the use of machine learning techniques that could accommodate non-linearity association. Machine learning is often characterised by five major approaches (i.e., association, classification, clustering, relationship modelling and reinforcement learning), each having already been applied for injury risk assessment and/or performance prediction in sports [9-13].

Conclusion • Complex systems are dynamic, open systems with distinctive characteristics. •

•

Machine learning 5 major approaches

Clustering

Relationship modelling

Association

Classification

Reinforcement learning

Figure 2. Major approaches of machine learning techniques

IMPORTANT POINTS ABOUT COMPLEX SYSTEMS

•

Complex systems is a theory in general science and has been applied in other fields as well.

•

They are dynamic, open systems with distinctive characteristics.

•

It is more than complicated or complex. It is a way of thinking and understanding the systems that we are living in.

•

It is challenging to analysis using a complex systems approach. Analytical techniques and machine learning model may be helpful in solving the problems.

Organisa� onal level

1. Bittencourt NFN, Meeuwisse WH, Mendonça LD, NettelAguirre A, Ocarino JM, Fonseca ST. Complex systems approach for sports injuries: moving from risk factor identification to injury pattern recognition—narrative review and new concept. British Journal of Sports Medicine. 2016;50(21):1309-14. 2. Bertalanffy LV. General System Theory: Foundations, Development, Applications. New York, USA: George Braziller Inc; 1969. 3. Philippe P, Mansi O. Nonlinearity in the Epidemiology of Complex Health and Disease Processes. Theoretical Medicine and Bioethics. 1998 December 01;19(6):591-607. 4. Von Bertalanffy L. The Theory of Open Systems in Physics and Biology. Science. 1950;111(2872):23-9.

We encourage a shift in paradigm to a complex systems approach when making decisions regarding return to play.

5. Philippe P, Garcia MR, West BJ. Evidence of ‘‘essential uncertainty’’ in emergency-ward length of stay. Fractals. 2004;12(02):197-209.

The use of computational modelling and machine learning techniques may have the capacity to identify the regularities of the pattern that emerged as a whole.

7. Joanna B, Alex P, Pete B-J, Martha B, Dione H. The visual representation of complexity: Definitions, examples & learning points. RSD7, Relating Systems Thinking and Design 7; 2018 23-26 Oct 2018; Turin, Italy; 2018.

6. Rickles D, Hawe P, Shiell A. A simple guide to chaos and complexity. Journal of Epidemiology and Community Health. 2007;61(11):933-7.

9. Ruddy J, Maniar N, Cormack S, Timmins R, Opar D. Predictive modelling of non-contact lower limb injuries in elite Australian footballers. Journal of Science and Medicine in Sport. 2018;21:S18. 10. Claudino JG, Capanema DdO, de Souza TV, Serrão JC, Machado Pereira AC, Nassis GP. Current Approaches to the Use of Artificial Intelligence for Injury Risk Assessment and Performance Prediction in Team Sports: a Systematic Review. Sports Medicine - Open. 2019 July 03;5(1):28. 11. Alessio Rossi LP, Paolo Cintia, F. Marcello Iaia, Javier Fernàndez, Daniel Medina. Effective injury forecasting in soccer with GPS training data and machine learning. PLoS ONE. 2019;13(7). 12. Cust EE, Sweeting AJ, Ball K, Robertson S. Machine and deep learning for sport-specific movement recognition: a systematic review of model development and performance. Journal of Sports Sciences. 2019 2019/03/04;37(5):568-600. 13. Fältström A, Kvist J, Bittencourt NFN, Mendonça LD, Hägglund M. Clinical Risk Profile for a Second Anterior Cruciate Ligament Injury in Female Soccer Players After Anterior Cruciate Ligament Reconstruction. The American Journal of Sports Medicine.0(0):0363546521999109.

8. Yung KK, Ardern CL, Serpiello FR, Robertson S. Characteristics of Complex Systems in Sports Injury Rehabilitation: Examples and Implications for Practice. Sports Medicine - Open. 2022 2022/02/22;8(1):24.

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COVID-19 RECOVERY IN ATHLETES: THE UK WORLD CLASS OLYMPIC AND PARALYMPIC EXPERIENCE FEATURE / CRAIG RANSON & JAMES HULL Introduction The COVID-19 pandemic has had and continues to have a devastating impact on global health. Within elite sport, there are typically three main considerations for health practitioners when assessing the athlete who has been infected with COVID-19. Firstly, the risk of illness to an athlete’s immediate health. During the early part of the pandemic, there was major concern over reports relating to a high incidence of COVID-19-related myocarditis in young athletes. Fortunately, subsequent well conducted studies provided some reassurance that this is not a common phenomenon in those with a previous diagnosis of COVID-19. Secondly, the nature of any guidance on acute management and subsequent return activity and duration recommendations. Thirdly, the identification of factors that indicate the likelihood of a prolonged recovery or ‘long COVID’ illness. What have we learnt from the UK World Class Olympic and Paralympic Sport experience? Practitioners from UK Home Country Sports Institutes (HCSI) in England, Scotland, Wales and Northern Ireland have closely monitored COVID-19 related illness in World Class Programme (WCP) Olympic and Paralympic Sport athletes, assessing the aforementioned factors. Since the onset of the pandemic in 2020 to the present time, there have been 410 recorded cases of COVID-19 related illness in 357 athletes (Figure 1). This equates to approximately one quarter of the WCP population experiencing over 10,000 time-loss days (restricted or unavailable to train). The context of that time-loss was particularly pertinent given the preparatory cycle for the Tokyo summer and Beijing Winter Olympic and Paralympic games, disrupted not only by widespread illness, but also the mandatory training and travel restrictions imposed as part of the global public health strategy to manage the pandemic. For the most part, COVID-19-related illness in the WCP cohort has been a relatively mild illness (i.e., not required hospital care or specific treatments). On balance, duration appears to be shorter lived as the pandemic progresses, with the median

Figure 1. WCP athlete COVID-19 cases recorded per month of incidence

number days of restricted training reducing from 18 days during the first year (to end Feb 2021) to 13 days in the second year. In late 2021 we published our experience of the impact of COVID-19 illness within the WCP1. In this analysis, we evaluated the pattern of symptoms at presentation (Box 1) and used this phenotype-based approach to provide insight regarding symptom clusters and how they might inform return to sport. The analysis found that whilst most infected athletes returned to full sport participation within two to three weeks, one quarter (23%) experienced restricted athlete training for over 28 days. Four percent of infected athletes were restricted for more than 100 days and a couple of those have been unable to return to elite sport participation. The phenotype prevalence was different in each of the first two waves. During the first wave (Feb 2020 – July 2020), 86% of cases were from one of three respiratory phenotypes and 26% had a specific lower respiratory focus e.g., dyspnoea and chest pain. However, during the second wave (Aug 2020 – Jan 2021) only 72% of cases were from a respiratory phenotype, with just 7% of all cases having a lower respiratory focus. This means that proportionally fewer athletes presented with respiratory symptoms and more athletes presented with general viral symptoms, such as headache and fatigue. Across the board, those with a lower respiratory phenotype were approximately twice as likely to result in more than 28 days time-loss. Our finding that approximately 1 in 4 athletes diagnosed with COVID-19 did not return to

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full training within 28 days was compared to our historical data that showed only 1 in 25 athletes diagnosed with a viral URTI had more than 28 days time-loss. Whilst HOW COVID-19 PRESENTED: THE 5 SYMPTOM PHENOTYPES

1. Upper respiratory focus (UR); sore throat +/- change in smell or taste or sinus problems reported +/- a cough +/- fever. 2. Lower respiratory focus (LR); presence of dyspnoea +/- chest pain +/- cough +/- fever +/- other lower respiratory tract symptoms; e.g. wheeze. 3. Cough only (CO); cough as the predominant symptom recorded and in the absence of co-existing dyspnoea and without other UR symptoms. 4.

Gastrointestinal (GI); with predominant symptoms being diarrhoea +/- nausea +/- abdominal pain.

5. Non-specific (NS); main clinical feature was fever, fatigue +/- headache +/myalgia but a lack of any prominent respiratory or GI symptoms. symptom duration was associated with training time-loss, another factor that may have contributed to this comparatively long impact on participation was the production of a HCSI COVID-19 Return to Play Protocol2. This protocol recommended a minimum of 17 days before full training or competition participation. This might now appear conservative, however in

football medicine & performance

Figure 2. HCSI COVID-19 Graduated Return to Play Protocol (updated 2022)4

2020, it was considered appropriate given the lack of knowledge about the disease severity and concerns about the potential cardiac implications of COVID-19.3 The updated 2022 protocol recommends time-scales more closely aligned to typical post-viral return to play (Figure 2).4 New waves and vaccination what do we know now? As we learn more about SARS CoV-2 and follow the global progress of this infection, it is now apparent that there is likely to be a long-term endemic state, punctuated with further outbreaks that are driven by new variants and vaccine escape. The availability of effective vaccines has significantly modified the clinical course and transmissibility of COVID-19. In the WCP we evaluated the tolerability of COVID-19 vaccination and found it was well tolerated and associated with very few significant side effects5. The most prevalent being arm pain around the injection site (in 94% of athletes), lasting a median of 2 days (IQR 1–3). Systemic side-effects were reported in 70% of participants, with short-lived generalised fatigue in 28% after the first vaccination (median 1 day [1–2]) and 37% after the second vaccination (1 day [1–3]). Conclusion It may be that COVID-19 is waning as a substantial public health threat, and thankfully, severe illness or death has been extremely rare amongst elite athlete populations. However, the trend for increased incidence with each wave of the pandemic balances the reducing impact on athlete availability per case. This means that future waves may continue to be a significant threat to optimal

A COMPARISON OF COVID-19 WITH TYPICAL VIRAL URTIS

• Lower respiratory phenotype triples an athlete’s risk of prolonged symptom duration and doubles their risk of prolonged time-loss. This highlights the importance of being able to distinguish between athletes with lower respiratory symptoms as they are more likely to require a longer period of recovery • Even an athlete with relatively mild COVID-19 symptoms is likely to have greater time-loss than an athlete with an URTI preparation for performance. Sharing data and experience with organisations and colleagues across the elite sporting landscape in the UK and overseas has proved invaluable. The benefits seen from this will hopefully lead to ongoing collaboration and resourcing that will allow collective and effective tackling of systemic athlete health challenges. KEY MESSAGES • In a cohort of elite athletes preparing for international competition, COVID-19 has largely resulted in a mild, self-limiting illness that does not require hospital care. • In the initial phases of the pandemic, approximately one quarter of athletes had not returned to full sport participation at day 28 after symptom onset. This is reducing as the disease and associated return to play protocols evolve. • The presence of clinical features implicating lower respiratory tract involvement (‘below the neck’ symptoms) was associated with prolonged illness and delayed return to full sport participation.

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HOW MIGHT IT IMPACT ON PRACTICE • Insight into the clinical course and time-loss following COVID-19 illness in elite athletes informs recovery management and athlete counselling. • Consideration could be given to expediting return to full sporting participation for those who present with symptoms primarily confined to the upper respiratory tract. • Further work is needed to determine the factors underpinning a delayed return to full sport participation following COVID-19 in some athletes. Acknowledgements We would like to acknowledge all the UK High Performance System and HCSI Athlete Health Practitioners for contributing to the WCP COVID-19 data collection and analysis. Those involved in producing the associated publications and guidance include HCSI colleagues; Dr Niall Elliott, Dr Anita Biswas, Dr Rhodri Martin, Dr Moiz Moghal, Dr Michael Loosemore, Mr Moses Wootten, and Ms Abbie Taylor.

1. Hull JH, Wootten M, Moghal M, et al. Clinical patterns, recovery time and prolonged impact of COVID-19 illness in international athletes: the UK experience. Br J Sports Med 2022; 56(1): 4-11. 2. Elliott N, Martin R, Heron N, Elliott J, Grimstead D, Biswas A. Infographic. Graduated return to play guidance following COVID-19 infection. British Journal of Sports Medicine 2020; 54(19): 1174-5. 3. Wilson MG, Hull JH, Rogers J, et al. Cardiorespiratory considerations for return-to-play in elite athletes after COVID-19 infection: a practical guide for sport and exercise medicine physicians. Br J Sports Med 2020; 54(19): 1157-61. 4. Elliott N, Biswas A, Heron N, et al. Graduated Return to Play after SARS-CoV-2 infection – what have we learned and why we’ve updated the guidance. Blog: British Journal of Sports Medicine; 2022. 5. Hull JH, Wootten M, Ranson C. Tolerability and impact of SARS-CoV-2 vaccination in elite athletes. Lancet Respir Med 2022; 10(1): e5-e6.

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INTERNS, PLACEMENTS & MORALS: AN ETHICAL TALE FEATURE / RYAN DEFREITAS Introduction The use of unpaid internships in elite sport has typically been used to boost departmental provision. At Leicester City, the club recognised the need to move away from what has often been associated with questionable and unethical working models to ensuring our ‘interns’ have the best possible experience at the Club. In this article, the clubs lead academy analyst, Ryan DeFreitas, now into his 9th season with the category one club, provides insight into the desire to extract real value from student involvement in performance analysis workflows. Desire & Drive Having obtained my own university qualifications, including an MSc in the Professional Practice of Performance Analysis, alongside my UEFA B, I understand the importance and place of academic and practical work experience in our evercompetitive industry. Ultimately, the goal of an effective student analyst programme is to provide value to the student, the department

and the overall hierarchy of the club, with my personal goal being to have each student analyst who works with me ready for full time employment by the time they leave. In bringing this to reality, I have worked closely together with Dr. Andrew Butterworth, firstly at the University of Derby, and more recently at Loughborough University, to develop ethical and enabling opportunities for both academic and professional development. Together we have enacted industry-leading practice in the provision of collaborative paid practical placements for student analysts as they simultaneously gain extensive applied experience alongside an outstanding postgraduate academic offer. Recruitment & Selection: What Do We Need Them For? Critical to the recruitment of aspiring analysts is evaluating the needs and strategy of the organisation. Ideally, the answer to that question won’t be, “We just need to film more training.

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Let’s get an intern in.” Immediately, that very basic example raises questions; Why do you need to film more training? Why should it be an intern that films? What benefit is this to the players, support staff & the student? Sure, there’s benefit to players and staff in being able obtain to footage to access feedback on their performances, but how much is too much? Equally, an aspiring analyst is not going to look back fondly on their time with you and your organisation if they’re stood outside in the rain all winter. I would argue that’s not appropriate preparation for full-time employment and I think you would find that difficult to rebut. At Leicester City we understand that a multitude of skills contribute to our provision and we recruit aspiring analysts with that in mind. We think widely about the holistic value that they will bring us, and we will bring them, not just the basic tasks that need covering. Given that we want to

football medicine & performance develop players by increasing access, engagement and learning moments, we must get the right people in to help facilitate. A student analyst with prior football experience definitely provides value, but so does an analyst with a background in high performance athletics, arguably more so. In this example not only can we better understand individual analysis engagement, but also on how analysis is delivered in different sports, prompting questions such as; is it instant on trackside? How does it lead to in competition? Do they receive the same in training and competition? We feel that accessing new information from students with varied backgrounds contributes to the strategies of the organisation and provides greater value in the first instance than an analyst who has experience in doing what we’re already doing because, to be honest, that’s the part I can teach. And so, our ideal scenario has been to have multiple student analysts at the club with variety in recruitment from different backgrounds providing new thinking and ideas. At Leicester City we have taken two to five student analysts each year, therefore we have the luxury of being able to consider a range of past experiences and skill sets. In order to do this, I ensure that the candidate base is varied and I am open minded as to the value each candidate can bring. This has developed over time with early intakes being particularly football heavy, which still bought success and met organisational need. Though now, I approach each year with a much bigger picture in mind and a gradual shift as each year has gone by towards wider experiences. As a department we are well invested in because I am able to demonstrate the value of our processes and that includes our student program. The needs of each organisation are different; however, universal elements of recruitment are finding people who want to learn, who fit the culture and with whom you feel an element of connectedness for a successful period together. Feedback & Competencies It soon becomes clear that student analysts develop as people and practitioners very quickly and so there is a need for regular feedback and reflective opportunities. In doing this, I consider industry developments, current skill sets, opportunity for development and career goals to develop an individualised curriculum of learning for each analyst. Developing this requires collaboration and input, and so we ask our student analysts

to complete a wide-ranging competency checklist for self-evaluation which includes basic technical tasks through to soft skills and relationship building. This, alongside my own detailed evaluation of the student and understanding their aspirations, provides a clear picture of developmental areas, USP’s and where we can work collaboratively to make them highly employable. Once established, continual monitoring, reflection and feedback is critical to continue the development of each analyst. I approach this with student analysts in the same way I do with full time staff under my management, albeit more regularly (e.g. monthly) to more effectively capture their rapid development and set short- and longterm objectives, challenging the students to work towards multiple competencies in set time frames. Not only does this develop the skills themselves, but also develop work balancing and time management. These reviews are initially driven from the competency checklist, which is updated and adapted as progression evolves, consistently linking back to career goals and the individual analysts’ particular talents. This is coupled closely with the academic learning and practice they receive through their excellent university course too, and I work closely with the academics to ensure alignment for assessments, projects and research. A year with the club is a relatively short period of time, and it is impossible to produce a finished article in that time. With this in mind, we ensure that as the student finishes their time with us, they leave with an individual development plan to continue beyond their time with us, with

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key actions and work on points to continually develop as they seek their next role. People Over Process The needs of the person and support required are paramount, above and beyond the practice of analysis. Entering into a professional club with experienced staff, big personalities and elite facilities can be daunting and often leads to a feeling of not belonging. So, I take it as a personal responsibility to treat students like staff, and offer additional advice, informal chats and advice to help lessen any feelings of anxiety. To further help this, as a club we have moved away from the term intern as this feels divisive or like they are a separate entity; all students who work with me are analysts. Some of those anxieties in student analysts may centre around approaching senior staff, imposter syndrome, logistics, travel or personal issues, all common in developing analysts. And so, I offer students an open opportunity to discuss, acting as a mentor professionally, but also personally, especially if their experiences relate to my own. This takes trust and relies on a good relationship having been built from the outset, which itself takes time and effort, but can result in enhanced work practice for myself and the students, alongside continued personal relationships and mentoring once the student has left the club. These conversations often happen informally, moving away from the worker-boss dynamic, and taking the form of informal meets over breakfast which I have found to bring out conversations that wouldn’t happen more formally. The student analysts who work with us are also full time University students, and so I have excellent relationships with Andrew,

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football medicine & performance

made to sit at separate desks but to have alongside full-time staff, or in their respective MDT offices, lets the department and also the wider staff know that our student analysts are just that, analysts, and are there to support. The way the analyst communicates with other MDT staff and what they feel is appropriate provision in specific contexts is real learning for the student and so we ensure the thought process, and intricacies of the situation, are fully supported and explained.

continually reflect alongside Andrew, on the effectiveness of the program and the benefits it brings to all involved. We also survey our past students in order to establish how they felt about their time with us, elements of the program they felt were effective and what changes they would have like to have seen made in order to make their time more positive or to increase their opportunity to learn. It is all information we can use to continually develop the program.

Integration & MDT Workflows By treating the student analyst as a fullyfledged member of the team and providing the benefits of my normal line management, integration in to the immediate department is simple enough. Naturally, there are always personality clashes in any workforce, however, by ensuring that recruitment processes consider candidate suitability to the culture and values of the organisation and with some level of personal connection then the team will likely be more cohesive and working towards the same guidelines in a positive environment.

I try to ensure exposure to other staff including coaches and players, alongside developing collaborative complimentary projects that aid the student’s proficiency and often dovetail with University assignments too. This ensures the holistic development of the analyst, linking to relationship building, soft skills and time management, with core responsibilities clearly outlined. It isn’t all linear though, and students experience both natural and controlled artificial road blocks on their journeys, in order to prepare the students for the types of moment when this happens in reality, and responsibility falls on their shoulders. The control of this is vital, ensuring that at no point does a situation occur naturally or artificially that is unsafe or potentially damaging, putting the hard-earned trust and vocational development at risk.

As per the start of this article, an effective program needs to serve the needs of the organisation and individuals within, and so I need to be able to demonstrate this. By cross referencing the work conducted by our student analysts and the value they provide, with the strategies of the club I am able to pinpoint how the program is assisting the academy in making progress with our 5-year strategic plan which can adapt and evolve with their help.

By treating students as staff, we see them participate in and contribute to departmental meetings which allows everyone to begin to feel they are on a level playing field, and starts to instil some responsibility in the student analysts. Even simple steps such as not being

Reviews & Success Our collaborative work with students is something that has developed over 8 seasons. The program now is almost unrecognisable to when we started. In order to continually develop I have had to

and the University, linking in with their own extensive personal tutoring processes and development plans, especially to help maintain a balance in time between both sides. That means ensuring that our students are on track with University work by allocating time to focus on assignments, keeping up to date with the insights created as they occur and planning regular contact. An added benefit of engaging with students rather than hiring additional permanent staff is the access to bespoke research. By helping design the research our students complete for their projects, this provides enormous value to the way the department and the organisation work as together we uncover novel insights for the betterment of our organisational goals.

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I entered the football industry due to a love of football. Now, over time and with experience, my true passion has become that of developing people. With that in mind, our record of employment postprogram is exceptional, and if that is a desirable measure of effectiveness then we would score very highly. I feel a great sense of pride that I was able to be a part of their journey and be a guide to them in their early careers. Our collaborative and holistic University student analyst program is something I have great belief in, developing opportunities for the next generation of dedicated and talented practitioners.

TOP 5 USES IN FOOTBALL by Gareth Thomas

1. POST-SURGERY KNEE – QUADS STREAM Quadriceps inhibition post knee surgery can lead to catastrophic muscle atrophy. This leads to prolonged recovery and unwanted deconditioning. Compex’s muscle stim technology is the best on the market for reversing these effects. Beginning with muscle atrophy programme, before moving through hypertrophy and strength programmes. These programmes can be enhanced further with the addition of combining Compex with early-stage exercises (such as isometric leg extension, squat, split squat, step up etc). This can be enhanced further with the use of BFR (Blood flow resistance) training.

2. POST-GAME RECOVERY Compex is the perfect travel partner to help players recover post-match. Especially on those long bus journeys back home where mobility and circulation can be compromised. Compex has a variety of programmes to optimise recovery. All of these programmes assist in improving circulation and blood flow, especially of the extremities, thus assisting venous return and removing waste products from the working muscles and enhancing recovery.

3. POST HAMSTRING SURGERY (BICEPS FEMORIS RUPTURE) If you have ever seen a biceps femoris rupture post-surgery, you will likely have seen the common complication that arises post-surgery. It’s common for the bicep femoris muscle activation and contraction to be minimised or non-existent. It’s observable when the player is trying to contract the hamstring muscles that the bicep femoris activation is reduced in comparison to the medial hamstrings. The Compex offers the perfect solution to this complication. By placing electrodes over the biceps femoris muscle only, beginning on muscle atrophy programme even just one application improves muscle activation significantly.

4. ANKLE SPRAIN REHAB Compex has its very own programme that is perfect to enhance proprioception post ankle injury. The ankle twist prevention programme is a great addition to rehabilitation to stimulate enhanced proprioception by stimulating peroneal muscle activity.

5. ACUTE STAGES MUSCLE INJURY Using the Compex post-acute muscle injury can reduce oedema, neuromuscular inhibition and muscle atrophy (Snyder et al 2010). Compex has a wide range of programmes that can optimise the physiology of muscle healing. Starting with capillarisation before progressing through the programmes. This helps to facilitate optimum recovery of these muscle injuries.

COMPEX® RECOVERY SELECTION

It can be sometimes difficult to select the best recovery method for players, based on recovery effectiveness, user diversity, costs/investment, easy application and understandability of a device. Compex® is a total solution brand for recovery. As the leaders in muscle stim technology, we enlarged our portfolio with a therapy range that offers effective, innovative, portable and easy-to-use products, to help progress training and optimise recovery. Come to us direct for great deals across our Recovery Range. Contact helen.cartwright@djoglobal.com for special FMPA deals and access to free Compex Muscle Stim Training.

MUSCLE STIM

AYRE BOOT

COMPEX.COM COMPEX_UK

@COMPEX_INT

COMPEXINTER

COMPEX_UK

Compex muscle stim devices stimulate the motor neurons in healthy people to improve muscle performance, increase blood flow and allow your muscle fibres to relax. The product is also intended to stimulate the sensory nerves in order to obtain analgesic effects. Compex electrostimulators have a medical certificate and are regulated in accordance with CE legislation.

FIXX MASSAGER

ION & MOLECULE

IN THE MUSCLE THE RESULT OF EXERCISE AND METABOLIC PROCESSES CAN BE: 1.

Lactate, metabolic waste, excess fluid in or around the muscle with a possibility of secondary symptoms of muscle soreness/pain (DOMS) and tensed muscles (stiffness, less mobility).

(Desperate) need for nutrients and oxygen for rebuilding.

Myofascial pain and stiffness (pain spots). Overuse or monotonous movements, circulatory and lymph drainage disorders and lack of oxygen, fluids and nutrients can result in sticky and brittle fascia (connective tissue): pain spots and (myofascial) stiffness.

Local and central neural fatigue.

POSSIBLE SOLUTIONS TO RESOLVE THE EFFECTS OF EXERCISE (RECOVERY): •

Clearance of lactate and metabolic waste by improving blood flow (venous return)

•

Flush out fluids by improving lymph drainage

•

Rebuilding “damaged” muscles by improving blood flow for bringing in nutrients and O2

•

Relaxation of the muscle

•

Relieve muscle soreness/pain (DOMS)

•

Relieve myofascial pain(spots)/trigger points/pain spots in muscle

•

Loosen myofascial stiffness

•

Calming the nerve system

MUSCLE STIM

AYRE BOOT

FIXX MASSAGER

ION & MOLECULE

••••• ••••• ••••• ••••• ••••• ••••• ••••• •••••

••••• ••••• ••••• ••••• ••••• •••••

20-30 min

20-50 min

60 sec

Improve lymph drainage (flush out fluids) Rebuilding “damaged” muscles by improving blood flow (bring in nutrients and O2) Relaxation of the muscle Relieve muscle soreness/pain (DOMS) Relieve myofascial pain (spots) /trigger points/pain spots in muscle Loosen myofascial stiffness Calming nerve system

SPORT RECOVERY EFFECTIVENESS Endurance-based sports (run, cycle, triathlon) Strength-/resistance-based sports Fitness and wellness High user diversity* Easy application** Easy to understand*** Recovery session duration, 1 muscle group

EXCELLENT VERY GOOD GOOD FAIR POOR

••••• ••••• ••••• ••••• •••••

CLARIFICATIONS *User diversity = based on the multi diversity of use of the device, recovery effectiveness and other purposes, like training. **Easy application = based on how much time it takes to start the recovery method as a first-time user. ***Easy to understand = based on the simplicity of using the machine as first-time user.

Compex and competitor products, to help provide a better and clearer understanding of the products.

Clear lactate and metabolic waste by improving blood flow (venous return)

Note: Ratings are estimations based on scientific studies, physiological literature and knowledge, and strategic market positioning of

RECOVERY EFFECTIVENESS

THREE P’S OF PRODUCTIVE PERFORMANCE

13TH,15TH & 17TH JUNE Education Co-Ordinator: Kevin Paxton

www.fmpa.co.uk/ conference-2022

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The 2022 FMPA Virtual Conference will take a critical look at three pillars producing effective performance. The people behind the scenes, the processes that they work by and because we are now in the generation of technology the products by which we use to continually improve our practise. The “Three P’s of Productive Performance” event will take place over 3 virtual workshops held over the second week of June and will provide around 11.5 hours of CPD for FMPA members. The event is FREE for FMPA Members and the content will be available to view for the whole of the 2022/2023 season. With 18 speakers from the world of UK football and supporting university programmes and professional standards bodies each of the workshop will cover one of the “Three P’s”.

2 3

Workshop 1: LIVE - MONDAY 13TH JUNE ‘22 DEVELOPING PEOPLE IN FOOTBALL What can organisations do to improve the knowledge base and co-operative work mentality to foster improved interdisciplinary support to athletes

Workshop 2: LIVE - WEDNESDAY 15TH JUNE ‘22 DEVELOPING PROCESSES IN FOOTBALL What can organisations do to simplify, resource and implement to enhance a co-operative interdisciplinary delivery to athletes

Workshop 3: LIVE - FRIDAY 17TH JUNE ‘22 DEVELOPING PRODUCTIVITY IN FOOTBALL What can organisations do to enhance the quality of feedback and review of interdisciplinary delivery to athletes to ensure high levels of productivity

A more detailed programme is available at https://www.fmpa.co.uk/fmpa-conference-2022/

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WORKSHOP 1 MONDAY 13TH JUNE 2022 DEVELOPING PEOPLE IN FOOTBALL What can organisations do to improve the knowledge base and co-operative work mentality to foster improved interdisciplinary support to athletes This workshop is designed to explore various strategies to develop the individual staff member to further improve the quality of support they provide to the players. Sometimes this can simply be some evidence based technical skills or knowledge on a specific case study in relation to others which could be extrapolated to suit their own environment. However, a vast percentage of personal development can be arguable achieved from developing personal characteristics or interpersonal communication strategies to impact upon the athlete by better interacting with other coaches and support staff or merely being more reflectively aware of how they can get better. Learning off external support mechanisms is fundamental to obtaining and honest and transparent improvement in knowledge and as such hopefully by exploring how links can be generated in this area will be of use. Good coaches throughout the world insist winning is simply getting better every time they train / compete irrelevant of the score-line. Another old adage is the athlete wont care how much you know until they can see how much you care and so a better understanding of our own personal frailties and knowledge gaps will be the first step on this path. And so if we can aim to and subsequently understand how to make ourselves better every day then we will be well on the way to become winners in the long run in both our athlete to coach relationship and ultimately success on the pitch.

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#FMPA2022

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WORKSHOP 1 MONDAY 13TH JUNE 2022 TIME

SUBJECT

SPEAKER

3.45pm

Welcome exhibitor advertisements

3.55pm

Opening Welcome

Eamonn Salmon, FMPA CEO Kevin Paxton, Education Lead

4.00pm

Managing and leading a Sports Medicine team in Football

Dr Zafar Iqbal Head of Medical, Crystal Palace FC

4.20pm

Use and implementation of development programmes within staffs pathway: remembering the person counts

Dr Steve Barrett Playermaker & UKSCA

5.00pm

Break and Exhibitors

5.15pm

Understanding the team around you, building working relationships

Sarah Murray, Sport & Exercise Psychologist, Performance Edge Consultancy

5.35pm

Bridging the gap between research and practice in football

Dr Stacey Emmonds Senior Lecturer in Sports Coaching Leeds Beckett University

5.55pm

Break and Exhibitors

6.10pm

Coaching, context & communication: Delivering critical insights in real time

Dr Andrew Butterworth Lecturer in Performance Analysis Loughborough University

6.30pm

Developing a holistic physical pathway

Tom Williams Head of Performance & Sports Science LA Galaxy

6.50pm

Eamonn Salmon FMPA CEO

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WORKSHOP 2 WEDNESDAY 15TH JUNE 2022 DEVELOPING PROCESSES IN FOOTBALL What can organisations do to simplify, resource and implement to enhance a co-operative interdisciplinary delivery to athletes This workshop is designed to explore various strategies to develop the day to day planning, delivery and review of our training processes and thereby improve the quality of support they provide to the players. Sometimes this can simply be some evidence based implementation of interventions or anecdotal knowledge on a specific case study. There is a saying that “ive always done it this way” is the most dangerous thought process a practitioner / department can display so hopefully by exploring different options on monitoring and assessments it may serve as a vehicle to help refine current ways of working in the clubs for the better. With this it is always nice to get a “well done” and this maybe in the form of external validation from another club utilisng similar or identical processes, which goes a long way in maintaining confidence in our work in such a volatile industry. Finally, it is also good to remember that there is a time and a place for everything and that sometimes a unique process maybe the best course of action at one specific moment in the season, with one specific player only. It may also be harder to implement than other easier processes but doing the right thing is not always the easiest.

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#FMPA2022

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WORKSHOP 2 WEDNESDAY 15TH JUNE 2022 TIME

SUBJECT

SPEAKER

3.45pm

Welcome exhibitor advertisements

3.55pm

Opening Welcome

Eamonn Salmon, FMPA CEO Kevin Paxton, Education Lead

4.00pm

The fundamentals of creating high performing shoulders for goalkeepers

Tim Stevenson Shoulder Strength and Conditioning Specialist Dynamic Shoulder

4.20pm

Return to Play – Are we actually doing enough?

Matt Willmott Head of Physical Performance, Swansea City FC

5.00pm

Break and Exhibitors

5.15pm

Inter-limb asymmetry: Calculation methods, individual data analysis and the importance of longitudinal monitoring

Dr Chris Bishop Director of Postgraduate Progammes in Sport London Sport Institute University of Middlesex

5.35pm

Interval running to aid in successful RTT – a multidisciplinary approach

Paul White Head of Academy Sports Science & Athletic Development Stoke City FC Academy

5.55pm

Break and Exhibitors

6.10pm

Conventional, tactical and dynamic periodisation: Understanding the physical component

Jack Sharkey Head of Sports Scientist Australian Women’s National Football Team

6.30pm

How to win friends and influence people: Lessons from a high performance environment

Andrew Wiseman Head of Performance

6.50pm

Eamonn Salmon FMPA CEO

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WORKSHOP 3 FRIDAY 17TH JUNE 2022 DEVELOPING PRODUCTIVITY IN FOOTBALL What can organisations do to enhance the quality of feedback and review of interdisciplinary delivery to athletes to ensure high levels of productivity This workshop is designed to explore various technologies, resources and innovations to develop the day to day planning, delivery and review of our training stimulus and dose response and thereby improve the quality of support they provide to the players. It should be noted to proceed with caution as we have often found over time that Briliant Basics do come out on top in most situations. The real question is can the human touch reduce how brilliant this can be and should we rely on more objective technological advancement in certain areas to get more brilliant outcomes and in a labour saving manner. If innovation can be utilised to refine, automate and improve the motivation of the player to work to their targets and simultaneously improve the ability of the practitioner to focus on their planning, interpersonal skills and coaching eye then surely this is a win-win situation.

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#FMPA2022

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WORKSHOP 3 FRIDAY 17TH JUNE 2022 TIME

SUBJECT

SPEAKER

3.45pm

Welcome exhibitor advertisements

3.55pm

Opening Welcome

Eamonn Salmon, FMPA CEO Kevin Paxton, Education Lead

4.00pm

Nutrition education strategies within academy football

Matt Westmoreland Nutritionist, Fulham FC

4.20pm

Complexity of Collection, Aggregation, and Communication of Human Performance Data in US Sport

Zach Shelly Director of Sports Science Strive

5.00pm

Break and Exhibitors

5.15pm

Joining the dots: the use of simple data structure to maximise analysis potential

Ben Mackenzie Academy Sport Scientist Leicester City FC

5.35pm

Strength, power and speed characteristics in elite academy soccer

Charlie Norton Sherwood Academy S & C Coach Arsenal FC

5.55pm

Break and Exhibitors

6.10pm

Using testing date to inform strength and power training in League 1 senior footballers

Irvin Mukandi, 1st Team Head S & C Coach, Ipswich Town FC

6.30pm

Integrating 23 individual schedules

Adam Burton Strength and Conditioning Coach England U18 / Leicester City FC

6.50pm

Eamonn Salmon FMPA CEO

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feature

IMAGING IN FOOTBALL MEDICINE FEATURE / M.BORDALO, E.YAMASHIRO, M.RASHED ALNAIMI & J.ARNAIZ THIS ARTICLE WAS PUBLISHED IN THE ASPETAR SPORTS MEDICINE JOURNAL VOLUME 10 TARGETED TOPIC 24- HOT TOPICS IN FOOTBALL MEDICINE. ASPETAR HAVE KINDLY AGREED FOR US TO SHARE THIS ARTICLE.

Lower extremity injuries are more common in football. In this chapter, we will review imaging aspects of the most frequent and important injuries in football players. GROIN PAIN Groin pain is a common problem in football players (10-14% of all injuries)5,6. The term groin

Imaging is an important arsenal in football medicine for guiding diagnosis, monitoring and treatment of sports injuries. An accurate diagnosis is required to design appropriate treatment and to determine prognosis in football players1. Imaging modalities are also utilized to guide interventional procedures in the treatment of several injuries. Imaging methods have been around for a while, but they constantly undergo technical advances, which improve lesion characterization and accuracy. The three pillars for an adequate diagnosis in high level football medicine are experience of the musculoskeletal radiologist, applicable techniques and up-to-date equipment. Football injuries can be acute or chronic from repetitive stress (overuse). In the professional level, ultrasound (US) and magnetic resonance imaging (MRI) are the methods of choice. Table 1 shows the major indications and disadvantages for the several imaging modalities. Return to play decision is fundamental to the practice of football and must balance a fast return to play with complete healing, recovery, and re-injury risk. Recent studies on medical imaging focus on prognostic radiologic features to support this challenging multifactorial decision2-4.

Table 1. Imaging modalities in sports medicine.

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pain in athletes is defined by four clinical conditions: (1) adductor, (2) pubic, (3) inguinal, and (4) iliopsoas-related groin pain (Figure 1), according to the “Doha agreement meeting on terminology and definitions in groin pain in athletes”7. Hip joint injuries and other conditions (sacroiliitis, nerve entrapment and intra-abdominal abnormalities) can also

football medicine & performance

cause groin pain and must be referred and managed. Diagnosis is based on clinical history and examination. Imaging will help in the diagnosis and classification of which condition (s) the injury applies. Adductor-related is the most common cause of groin pain is football players8,9. A combination of rectus abdominis and adductor longus strains are predominantly found. The injury can extend to the rectusadductor aponeurosis at the symphysis pubis. US is the first-line image modality and MR gives a more detailed analysis. These methods can demonstrate adductor tendon abnormalities such as inflammation or ruptures (Figures 2, 3, 4). Cortical irregularities and calcifications are common in asymptomatic athletes (Figure 5). There is a close anatomic relationship between adductor tendons and the pubic symphysis. On imaging, pubic-related groin pain condition is seen on MRI as pubic bone edema, which may also occur along with other groin pain conditions9. It is important to state that subtle pubic bone edema on MRI is also frequently seen in asymptomatic athletes. However, as the athletes become more symptomatic, bone edema increases and other features are present, such as fluid within the pubic symphysis joint and periarticular edema (Figure 6). Chronic features (pubic spurs and cortical irregularities) are commonly present in athletes with a past history of groin pain (Figure 7). It is accepted that the pubic-related groin pain entity is on a spectrum of stress changes from asymptomatic athletes to degenerative changes in chronic cases. In the iliopsoas-related groin pain, MRI and US can demonstrate iliopsoas tendinopathy and bursitis (Figure 8). US is the best imaging modality to evaluate inguinal-related groin pain. Although rare in athletes, dynamic US is highly accurate to diagnose inguinal and femoral herniation (Figure 9). Inguinal wall motion is present in many symptomatic and asymptomatic athletes, making clinical correlation mandatory. MRI is usually normal in the evaluation of the inguinal region. MUSCLE INJURIES Technical advances in US technology provided some advantages in the evaluation of muscle injuries, compared to MRI: relatively cheap and widely available, comparable spatial resolution, allows portability, dynamic evaluation, serial evaluation to follow

healing and real-time guidance for muscle injections. However, MRI is considered the reference imaging method to assess muscle injuries in athletes due to excellent contrast, high resolution, and the ability to evaluate soft tissue. Also, MRI provides better evaluation of deep muscle compartments and demonstrates scar tissue formation at the site of injury. US features of muscle injuries are loss of fascicular pattern with fiber disruption, hypoechoic and/ or hyperechoic focal areas within the muscle and focal or complete fiber discontinuity. Usually, fiber discontinuity occurs at the myofascial junction or around the musculotendinous junction, however it can occur at any location within the muscle (Figure 10). MRI most classic feature of muscle injury is diffuse ill-defined high signal intensity change (called “edema”) on fluidsensitive sequences. When edema is found around the musculotendinous junction, we may have the classic “feathery” appearance (Figure 11). Fiber discontinuity is seen as a focal area of well-defined high signal intensity (Figure 12). Muscle injuries may also occur far from the musculotendinous junction and at the peripheral myofascial junction10 (Figure 13). There are several imaging classification systems for muscle injuries (table 2)11-14. The classic 1-3 classification system lacks diagnostic accuracy and provides limited prognostic information. The grade 1 injury is defined as edematous pattern without muscle disruption on MRI. US can be negative or show illdefined areas of increased echogenicity. Grade 2 is defined as an area of focal fiber disruption and grade 3, complete disruption of the musculotendinous unit with fluid (hematoma) filling the gap created by the tear10 (Figures 14 and 15). However, the presence of intramuscular hematoma can also occur in muscle contusions and grade 2 tears. Dynamic evaluation of muscle tears on US is useful to evaluate the presence of fiber disruption. The Munich consensus on classification of muscle injuries included grades according to the cause of the injury13. Another recent classification system is based on extent and location of injury (myofascial junction, intramuscular and tendinous)14. Adequate staging of the muscle injury is crucial, avoiding underestimation of the injury and

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consequent recurrent muscle tear because of a premature return-to-play. Hamstring musculotendinous tears are the most common injuries in football, representing 10-37% of all injuries6,15. The hamstring complex is in the posterior compartment of the thigh and includes the semimembranosus, semitendinosus, and biceps femoris muscles. In football, the most injured muscle is the biceps femoris and over half of the cases involve more than one hamstring muscle. Most frequently, the proximal and distal musculotendinous junctions are injured6,16 (Figure 16). Apophysitis and avulsion of the ischial tuberosity (the site of origin for the hamstring and hip adductor tendons) is seen most frequently in skeletallyimmature players17 (Figure 17). Some imaging findings are associated with a longer rehabilitation time: the presence of injury at MRI, injury of the proximal or intramuscular tendon at the deep musculotendinous junction and greater longitudinal length of the muscle injury1,4,16(Figure 16). A negativeMRI is associated with a favorable recovery prognosis11. However, based on the current literature, MR and US findings alone do not provide accurate information for prediction of time to return-to-play after a muscle injury18. The rectus femoris is the most frequently injured muscle of the quadriceps complex. Injuries are located at the origin of the direct and indirect heads, proximal musculotendinous junction, deep musculotendinous junction of the indirect head and distal musculotendinous junction close to the knee joint19. More common injuries are located in the deep musculotendinous junction of the indirect head and are related to a longer return-to-play time20,21. The “bull’s-eye” pattern is the most frequently observed finding in MRI20,22 (Figure 18). A specific kind of lesion, the degloving injury, is seen in 9% of rectus femoris tears whereas the inner bipennate intramuscular portion of the indirect musculotendinous complex is separated from the surrounding superficial unipennate portion of the rectus femoris23 (Figure 19). Acute avulsion fractures and chronic traction apophysitis of the origin of the direct head at the anterior inferior iliac spine are more common in skeletallyimmature players17,24 (Figure 20).

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Figure 1: Groin-pain in athletes - Four clinical conditions and anatomic correlation: Pubic, adductor, iliopsoas and Inguinal – related groin pain (Modified from reference 7, with permission). Figure 2: Adductor tendon rupture – MRI. Male football player, 22 years-old. Coronal (a) and axial (b) T2-weighted fat-suppressed magnetic resonance (MR) images of the pubic region show a complete rupture of the origin of the adductor longus tendon at the pubic bone, with a 3,0cm distal retraction of the tendon and muscle (white arrows in a and b). There is a small hematoma at the rupture site (black arrow in b).

Figure 3: Adductor tendon rupture – US. Male football player, 24 years-old. Longitudinal US image of the adductor longus muscle. There is a complete rupture of the origin of the adductor longus tendon with a gap of 4,0 cm and a distal retraction of the tendon and muscle. Figure 4: Adductor longus muscle strain – US. Male football player, 19 years-old. Transverse US image at the middle third of the adductor longus muscle. There is a grade 2 strain, represented by the hyperechoic area within the muscle. Figure 5: Adductor longus tendinopathy – US. Male football player, 31 yearsold, asymptomatic. There is thickening and heterogeneity of the origin of the adductor longus tendon with a deep partial rupture. There are bone irregularities at the adjacent pubic bone.

Figure 6: Osteitis pubis. Coronal T2-weighted fat-suppressed MR image of the pubic symphysis in a symptomatic 37 years-old football player. Pubic bone edema, fluid within the joint and a tear at the left adductor longus tendon origin (typical secondary cleft sign). Figure 7: Chronic changes in the pubic symphysis. Coronal T2-weighted fatsuppressed MR image of the pubic symphysis in an asymptomatic 34 years-old football player. Osteophytes and bone irregularities in the pubic symphysis (circle). Figure 8: Iliopsoas tendon strain. Axial T2-weighted fat-suppressed MR image of the pelvis in a 12 year-old girl, injured during a football game. There is a tear in the iliopsoas tendon at the insertion on the lesser trochanter of the femur, with associated bone marrow edema. Figure 9: Sports hernia. US transverse images of inguinal region while resting and during Valsalva maneuvers. There is bulging of the epiploic fat between the rectus abdominal muscle and epigastric veins after Valsalva maneuvers, indicating a sports hernia.

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Figure 10: Grade 2 muscle injury. US longitudinal image of the posterior thigh. There is a hyperechoic area (white dotted area) and loss of the fibrillar pattern within the semimembranosus muscle (red dotted area), indicating an injury.

Figure 11: Muscle injury – “Feathery” appearance. Coronal T2-weighted fat-suppressed MR image of the thigh shows edema around the intramuscular musculotendinous junction (arrow), with the classic “feathery” appearance. Figure 12: Focal fiber discontinuity on MRI. Axial T2-weighted fat-suppressed MR image of the thigh shows focal fiber discontinuity of the vastus intermedius muscle (arrow). Figure 13: Myofascial muscle injury. Axial T2-weighted fat-suppressed MR image of the thigh. There is edema of the peripheral myofascial portion of the rectus femoris, indicating an injury.

KNEE INJURIES Knee is frequently injured in football (18% of all injuries)5,6. The knee joint is exposed to elevated risk of injury, either acute trauma or chronic overuse injuries and is subject to stress from indirect and direct forces. Usually knee injuries have a worse effect on return-to-play and accelerate development of knee osteoarthritis25. Anterior cruciate ligament (ACL) tears are prevalent in children and women and MRI is the modality of choice for its evaluation. The pivot-shift is the most common noncontact mechanism involved in ACL injury, creating the typical osseous contusions of the anterior lateral femoral condyle and posterior aspect of the lateral tibial plateau (Figure 21). On acute phase, ACL injuries typically produce hemarthrosis, focal ligament discontinuity or diffuse thickening and edema. Also, abnormal ligament fiber orientation is seen (Figure 22). Secondary MRI signs are anterior translation of the lateral femoral condyle, uncovering of the posterior horn of the lateral meniscus and PCL buckling26.

Meniscal tears in football players are usually secondary to acute trauma, isolated or associated with ACL or chondral injuries. They are most common at the posterior horn of the medial meniscus; however, in young patients with acute injuries, lateral meniscal tears are common. MRI is highly accurate for the diagnosis of a meniscal tear, which is classified according to its direction and location: longitudinal, vertical, horizontal and radial tears27 (Figure 21). A meniscal ramp lesion is located at the meniscocapsular junction of the posterior horn of the medial meniscus and is strongly associated with ACL tears28 (Figure 23). Identification of displaced meniscal tears on MRI is important in patient management and preoperative planning (Figure 24). Medial collateral ligament (MCL) injury is the second more common type of injury in football, after hamstring injuries, although injury rates have decreased in the last decade. MCL injury is more

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commonly caused by contact than noncontact situations29. MRI is the imaging modality of choice to demonstrate the three types of injuries: Grade 1: peri-ligamentous edema; Grade 2: thickened and edematous MCL and Grade 3: complete MCL tear (Figure 25). Although US is not frequently ordered to assess the MCL, US features for MCL tear have been described and dynamic maneuvers with valgus stress are useful for diagnosis of grade 3 tears30. Patellar tendinopathy is seen in skeletally mature football players, and describes a spectrum of disorders at the proximal insertion of the patellar tendon31. Diagnosis can be performed by ultrasound and MRI (Figure 26). Knee osteoarthritis is common in football players. However, studies show that this condition is less likely to cause functional disability32. The main predisposing factor for development of early osteoarthritis in football players is direct trauma with potential surgical consequences33 (Figure 27).

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Table 2. Imaging classification systems for muscle injuries.

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Figure 14: Classic muscle injury grading on MRI. Grade 1: edematous pattern without muscle disruption on MRI. Grade 2: area of focal fiber disruption (fluid-signal area within the muscle). Grade 3: complete disruption of the musculotendinous unit with fluid (hematoma) filling the gap created by the tear. Figure 15: Classic muscle injury grading on US. Grade 1: ill-defined areas of increased echogenicity. Grade 2: area of focal fiber disruption (welldefined anechoic or hyperechoic areas within the muscle). Grade 3: complete disruption of the musculotendinous unit with fluid (hematoma) filling the gap created by the tear. Figure 16: Biceps femoris musculotendinous junction injury. (a) Axial and (b) coronal T2weighted fat-suppressed MR images of the thigh. There is a grade 2 injury of the proximal musculotendinous junction of the right biceps femoris with edema. Compare with the normal left biceps femoris intramuscular tendon (in b). Figure 17: Hamstring apophysitis. 14 years-old female football player. Axial T2-weighted fatsuppressed MR image of the pelvis shows edema and bone irregularities at the origin of the semimembranosus tendon at the ischial tuberosity, compatible with apophysitis

Figure 18: “Bull’s-eye” pattern injury. Axial T2-weighted fat-suppressed MR image of the left thigh shows edema surrounding the intramuscular musculotendinous junction of the rectus femoris and the typical “bull’s-eye pattern Figure 19: Degloving injury – rectus femoris. (a) Axial and (b) coronal T2-weighted fatsuppressed MR images of the thigh. Inner and outer muscle portions of rectus femoris are separated by fluid (arrows). The coronal image (in b) shows retraction of the inner muscle.

Figure 22: Complete ACL tear. Sagittal T2-weighted fat-suppressed MR image of the knee. There is a complete tear of the proximal aspect of the ACL with horizontalization of its distal fibers (arrow). Figure 23: Meniscal Ramp lesion. Sagittal T2-weighted fat-suppressed MR image of the knee shows a vertical tear at the posterior meniscocapsular junction of the medial meniscus (arrow).

Figure 20: Rectus femoris avulsion. 13 yearsold boy injured during a football game. (a) Axial, (b) coronal and (c) sagittal T2-weighted fat-suppressed MR images of the pelvis show avulsion of the anterior inferior iliac spine, at the origin of the direct head of the rectus femoris (arrows). Figure 21: Typical bone contusions in ACL injury. Sagittal T2-weighted fat-suppressed MR image of the knee. Bone marrow edema in the anterior lateral femoral condyle (white arrow) and in the posterior aspect of the lateral tibial plateau (black arrow). There is a meniscal tear in the posterior horn of the lateral meniscus (arrowhead).

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25 Figure 24: Meniscal bucket-handle tear. (a) Sagittal, (b) coronal and (c) axial T2-weighted fat-suppressed MR images of the knee. Complete vertical tear of the medial meniscus with displacement of the inner part of the meniscus to the intercondylar notch (arrows - bucket-handle tear). Note the typical “double-PCL sign” (in a), the remaining medial meniscus (in b and c) and the appearance of a bucket-handle that the displaced meniscal fragment creates with the remaining meniscus (in c). PCL: Posterior cruciate ligament. Figure 25: MCL tear - grades. Grade 1: edema surrounding the ligament. Grade 2: thickening and edema within the ligament. Grade 3: complete ligament tear.

Figure 26: Patellar tendinopathy. 20 years-old male football player. Sagittal T2-weighted fat-suppressed MR image of the knee demonstrates thickening and edema at the origin of the patellar tendon (circle - tendinopathy). Figure 27: Osteoarthritis. 23 years-old asymptomatic male football player. (a) Coronal and (b) sagittal T2-weighted fat-suppressed MR images of the knee. Severe osteoarthritis in the patellofemoral and lateral femorotibial compartments, with diffuse and advanced chondral erosions, osteophytes, subchondral edema, degenerative meniscal tear with extrusion and loose bodies surrounding the popliteus muscle (arrows in b). Figure 28: Ankle strain. 18 years-old male football player. Ankle strain during a game. (a) Axial and (b) coronal T2-weighted fatsuppressed MR images of the ankle. There is diffuse subcutaneous edema around the ankle, anterior talofibular ligament (ATFL) strain (arrow in a) and deltoid ligament strain (arrow in b).

Figure 29: Achilles tendinopathy. Longitudinal US image of the posterior ankle. There is thickening and heterogeneity of the Achilles tendon, indicating tendinopathy. Figure 30: Achilles tendon rupture. Sagittal T2-weighted fatsuppressed MR image of the ankle shows complete rupture of the proximal portion of the Achilles tendon (arrows).

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football medicine & performance

Figure 31: Platelet-rich plasma (PRP) injection. Images demonstrating US-guided injection of PRP technique.

Figure 32: Platelet-rich plasma (PRP) injection – US images. (a) Transverse image of the ankle demonstrates a chronic Achilles tendinopathy and thickening and hypoechogenecity of the fascia cruris, indicating an injury. In this image, the needle is positioned over the fascia cruris.(b) Transverse image of the ankle after the injection of the PRP concentrate.

ANKLE INJURIES The ankle is commonly injured in football, corresponding to 14% of all injuries6. Acute injuries are common and related to inversion injury of the ankle. Imaging is performed in cases where clinical diagnosis and grading is difficult and when there is development of chronic sequelae34. In the ankle, MRI has the advantage over US of providing a global assessment including osseous and chondral injuries. However, for confirmation of tendon and ligament disorders of the ankle, US is very useful. Ligament injuries from inversion sprains are common, however ankle stability is maintained by muscle recruitment and scar tissue and treatment is mainly conservative. Lateral ligament injuries are more common than medial ligament and syndesmotic injuries (Figure 28). Achilles tendon disorders are relatively common in football, however injuries have decreased in recent years because of understanding of injury biomechanics and consequent modification of training protocols. Both methods, US and MR, are indicated for assessment of the Achilles tendon (Figures 29 and 30). All types of ankle impingements syndromes are common in football players, especially 2-4 weeks after an acute injury. MR imaging is accurate

for assessing soft tissue and osseous abnormalities involved in the impingement syndrome. US is more useful to correlate clinical symptoms with imaging findings. IMAGE-GUIDED INTERVENTION Image-guided therapeutic interventions provide minimally-invasive treatments and can be performed in the acute and chronic settings. Real-time imaging guidance of interventional procedures, such as articular joint and tendon injections is advantageous over blind techniques in terms of greater accuracy and effectivity (the needle is accurately placed and medication is injected in the right place), patient safety (lesser risks of complication due to reduced risk of inadvertent injury to adjacent structures), patient comfort (less postprocedural pain, faster recovery and shorter stay) and consequent increase in treatment costeffectivity35. Improvement of imaging modalities, new technologies and materials also made possible the development of new intervention techniques, such as viscosupplementation, platelet-rich plasma and stem cell therapies, that may become potential state-of-the-art treatments in the future36 (Figures 31 and 32).

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SUMMARY Various injuries occur in football players, especially in the lower extremities. Imaging allows fast and accurate diagnosis for the athletes, facilitating treatment. Imageguided interventions are the mainstay of nonsurgical intervention in athletes and can be used to treat several injuries. References Available at www.aspetar.com/journal

Marcelo Bordalo M.D. Chief of Radiology Aspetar Orthopaedic and Sports Medicine Hospital (Doha, Qatar) Eduardo Yamashiro M.D. Radiologist Aspetar Orthopaedic and Sports Medicine Hospital (Doha, Qatar) Maryam Rashed Alnaimi M.D. Radiologist Aspetar Orthopaedic and Sports Medicine Hospital (Doha, Qatar) Javier Arnaiz M.D. Radiologist Aspetar Orthopaedic and Sports Medicine Hospital (Doha, Qatar)

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LESSONS LEARNED FROM 10 YEARS OF PERIODIC HEALTH EVALUATIONS FEATURE / DUSTIN NABHAN & CARLOS JIMÉNEZ Introduction At the elite level of sport, periodic health evaluations (PHE) have evolved from basic outpatient medical check-ups to robust, integrated, and multi-disciplinary events designed to protect athlete health and optimise performance. There is an arms race between elite organisations in how PHEs are performed, what technology is used to assess athletes, and how the data is analysed and used for future decision-making. However, there is controversy regarding the efficacy of the PHE. We argue that PHEs play an important role in prevention and aim to provide a list of lessons learned from over a decade of screening in elite sport to support this.

Lessons Learned 1.

Start with WHY.

During the 2003 Confed Cup, the Cameroon star Marc Vivien Foe collapsed on the pitch and died of sudden cardiac arrest. This startling wake-up call to the football medical community led to FIFA’s development of the Pre-Competition Medical Assessment (PCMA), a PHE program that has been compulsory in the men’s game since 2006 and for women and youth since 2007[1]. The PCMA is designed to detect athletes who are predisposed to severe medical conditions that could lead to sudden death, such as hypertrophic cardiomyopathy or arrhythmias, and ensure current medical conditions are managed appropriately as well as identifying risk factors for future injuries.

Whether this type of screening is effective for prevention is not clear from the current body of literature. While early research from Italy suggested that organized cardiac screening programs may reduce the incidence of sudden death in sport, retrospective studies from Norway and the UK have shown that these programs can miss athletes who may go on to have cardiac events [2,3,4]. This begs the question, without the promise of prediction, what is the value of the PHE? We believe every sport organisation must prioritise the reasons they are performing a PHE, and use these as principles for program design. The following table details some of the objectives for the PHE. 2.

Current symptomatic health problems

Occult health problems

Determine general physical and psychological health Determine eligibility for sport participation Ensure current health problems are managed appropriately Screen for silent medical conditions, with an emphasis on identifying conditions associated with sudden cardiac death Identify risk factors for future injury

Risk factor identification

Introduce prevention strategies for athletes at risk Document and review the past medical history Identify barriers to performance

Performance

Baseline data collection

Performance analysis in sport science disciplines (nutrition, biomechanics, physiology, psychology) Collect baseline data to use as a diagnostic tool in the event of future injury Collect baseline data to use as a benchmark for return to play decision making in the event of future injury Develop relationships between athletes and medical staff

Education & Relationships

Serve as a portal of entry into the healthcare system Opportunity to provide education on health topics and available resources

Medicolegal & Anti-doping

Satisfy requirements of sport federations, local government, and regional standards of care for periodic screening of athletes/employees Review medications and vaccination history for medical and anti-doping risk management

Table 1. Objectives of the PHE

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queeze the juice out of your S team of experts BEFORE the planning process

The PHE was traditionally a clinical encounter by sports medicine physicians. But new evidence tells us this has changed. In 2021, we surveyed the top 8 medal count finishers from the 2016 Summer Olympic Games and 2018 Winter Olympic Games to find out how these countries approached PHEs [6]. We learned that an average of seven medical and science specialties were involved in the PHE, which included an average of 25 different elements. This highlights the expanding role of the PHE as an integrated, multidisciplinary endeavour with many aims. What surprised us was that despite the many disciplines involved, the majority of these specialists were not involved in the planning process: test selection, determining thresholds for action, determining how findings will be communicated, etc. The planning work was performed by physicians and physios, while other experts such as fitness coaches, dietitians, and psychologists were often not included. We believe that involving your team of experts early is necessary for optimal delivery of PHEs. Plan for PHEs with all staff meetings to create a multidisciplinary strategy to screening.

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Know your enemy

PHE programs should target the conditions that have the greatest burden on the athletes being tested. Sports medicine teams should dedicate substantial time into studying the population they work with using literature reviews, analyse data from their own team (retrospective season analysis), and the health history of the players on the current roster using medical record reviews and athlete interviews [7]. Conditions suitable for screening should be prioritised if [8]: 1) 2) 3) 4)

hey are severe (pose danger to life) T or result in extensive time lost (ACL) They have high incidence or are persistent (tendinopathy) [9] There is a suitable test (valid, reliable, cost-effective) A positive screen can lead to a safe and effective treatment

Professional football is one of the few sports in which detailed epidemiological work has been documented in both male and female populations. Figure 1 (below) provides a summary of literature reviews on the most common injuries in professional football.

alk to your athlete (they have T important things to tell you)

The best predictor of future injury is previous injuries. We spend countless hours validating the tools we use to assess our athletes, but how much time do we spend learning more about an athlete’s medical history? In many sports medicine settings, medical records are incomplete, past medical histories are unavailable, and we have to depend on the athlete to explain their health history to us. We learned that we can identify 4 times as many significant injuries than when we ask athletes to use health forms to provide their medical history [13]. As a result, we believe every health history should start with a conversation between the athlete and their lead medical provider. 5.

out of 4 outcomes of screening tests 3 are bad--choose your tests wisely

If you are passionate about medical screening, pick up a copy of Angela Raffles’ “Screening, Evidence and Practice”. Raffle is a consultant for the UK National Screening Programmes, where she studies and designs large-scale medical screens for the general population. Raffle’s experience with the perils of medical screening leads to the guidance we must all consider; for every test that we perform, there are 4 outcomes, and only one of them is good[14]:

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ou find a condition in its early stage, it Y is treatable, and your early identification improves the patient’s outcome (Great!) You find a condition in its early stage, then the condition is on a course that cannot be changed and your early treatment has no change in the patient’s prognosis (No effect) You find a condition and treat it, but early detection provides no advantage over detecting the condition once it is asymptomatic (No effect over usual care) You think you find a condition, but it is a false positive (or insignificant finding) and the patient undergoes unnecessary treatment/anxiety (Bad)

Every time a new screening test is chosen, these 4 outcomes must be considered before the test is implemented. By documenting your program’s results and tracking them over time, you can make better decisions about what tests are best for your team. For examples of this, consider van Dyk’s work on hamstring strength testing and Krosshaug’s long-term results of drop jump testing for ACL injury prevention[15,16]. 6.

You can’t find what you can’t measure

You may find yourself in a setting where you don’t know if adding a test will have any yield in your population. If the test is safe, and you have the resources to include it, sometimes

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piloting a test is the best way to determine long-term value. Case in point, serum ferritin screening in male athletes. Iron deficiency is the most common nutritional deficiency worldwide, however in the athletic population, many consider this to be a problem only relevant to females. We reviewed data from 5 years of Olympic and Paralympic athletes in the US, and found that a surprising 15% of elite male athletes were found to be iron deficient[17]. In one anecdotal case, over 85% of one male National team was iron deficient. This test, which is important for both health and performance, was able to help us identify many athletes with treatable conditions that would have been missed with conventional wisdom. There are situations in which there will not be much evidence specific to your setting or population to guide you in test selection. Pilot projects may help determine the value of new tests in these situations. 7.

The more you test, the more you find

The most comprehensive study of PHEs in elite football is probably from Dr. Arnhild Bakken, who reported the findings of the Aspetar football screening program for Qatar Stars league athletes[18]. When reviewing the findings of 533 athletes over a two-year period, the PHE led to temporary medical holds for 12% of participants, although after completing further tests only one of the 533 athletes was medically disqualified.

However, 96% of players required medical follow-up or treatment of some kind, usually for general medical or musculoskeletal conditions. Did these findings result in better health for the athlete? We don’t know. Bakken and her colleagues noted that the high prevalence of conditions identified is an artefact of having a comprehensive testing battery. Every test you add to a PHE increases the odds of having an abnormal result. The science of PHE development hinges on weighing the risk and benefits of these tests based on their efficacy and the resources required to complete them. 8.

Be pre-armed with action plans

Don’t just test to test. It’s important to have a clear vision and reason for why you are implementing a battery of tests with a team. Any question or task posed to an athlete through a PHE needs to have a follow-up protocol to appropriately address the results of the question. The below example on hamstring injuries illustrates how to set clear action plans based on the results of a PHE. Action plans need to be taken into consideration from a team approach, semi-individual approach and individual approach depending on the risk factors found during the health evaluation (fig 2) [19,20,21,22]. We must accept and be able to adapt our plans and strategies from pre-season through in-season assessments and understand that athletes will be moving through low and high risks times depending on the time of the season and many other factors. [23]

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All is lost in absence of data hygiene

Long-term efficacy of screening programs can only be evaluated if the data is collected and analysed with proper structure and format. Many organisations lose potential value in their screening programs because of simple data hygiene errors. Did you know that data wrangling and cleaning is about ~60% of data scientist’s job? This is one of the most important steps before taking data from a screening program into action. Not thinking two to three steps down the road when creating a process can lead to dirty data being recorded and can be catastrophic for your organisation. For instance, dirty data can result in a poor or low level of analytics, end-user frustration, diminished productivity, trouble in growing the data analytics department, etc. If we think of data quality, we must create a process where data is clean at all times. Working with data can be frustrating, especially if using different technologies that utilise their own way of writing data in the “cloud”. As we know, many sporting organisations will struggle when using multiple pieces of technology/ surveys to monitor weekly neuromuscular fatigue, daily wellness questionnaires, and global positioning systems recording with hundreds or even thousands of data points per day. Real-world example: athlete ID Do you use name, middle name, and last name? John_C_Dane Do you use aliases/nicknames? Johny, Johnnie, John_John

football medicine & performance Do you use name, middle name and last name, and date of birth? John_C_Dane_07_10_1986 Do you use name, middle name and last name, and athlete’s position? John_C_Dane_CM Do you have a unique ID number provided by the data science team? jcd_1234_cm We believe the latter is the best way to move forward before thinking about the collection of data. The last crucial step before deploying any method of data collection is to validate the process with staff, stakeholders, and other end users. This feedback loop will help find errors and problems to refine the process that may lead to dirty data in the cloud and a poor user experience. Also, involving those key members that will be utilizing the system will increase acceptance and improve long-term usage of the tool that is being created. 10. P rediction is probably not possible… but that doesn’t mean we stop screening

Missing values Completeness

•

Which limb was tested left or right?

•

No data recorded when using the handheld dynamometry (malfunction hardware or software)

Date or name •

Which way are you saving the record using alias/name/uniqueID?

•

mm/day/year or day/mm/year

Accuracy Manual entries •

Did the sports scientist enter the correct value for the weigh-in/out?

•

Was the name written equivocally during testing?

Data stored in non-standard values Conformity

•

Assuring the data variable matches the original format (Hamstring force is recorded in Newtons = Numerical)

•

Data value should be transformed to date format

Identify barriers to performance Performance

Consistency Duplicates

Performance analysis in sport science disciplines (nutrition, biomechanics, physiology, psychology) Structure of the data •

Variables match the observation

Double entries same day •

Did the athlete re-submit the same answer the same day?

Table 2. Data quality assessment: [24]

In 2016 Professor Roald Bar wrote a controversial critical review on the predictive value of screening tests[25]. He called out many of the scientific flaws that we describe in this article, most importantly that it is very hard (maybe impossible) to predict musculoskeletal injuries with screening tests. Bahr’s argument went viral, but many missed his important argument in the closing statements, in which he lists the many benefits of engaging athletes in regular medical screenings. For example, the PHE may be the athlete’s first encounter with their sports medicine team and it can be used to develop rapport between athletes and staff, as well as serving as an opportunity to act as a baseline for physical performance scores. In summary- KEEP SCREENING, just be aware of the pitfalls of this often misunderstood component of athlete health protection. Conclusion The PHE is a special opportunity for medical and science staff to perform structured and action-oriented assessments on their athletes. A strategic approach is necessary to harvest the potential health and performance benefits, this strategy requires the combined knowledge and expertise of the entire sports medicine and science team. By treating the screening process as a living experiment, in which you learn from your outcomes over time, and by focusing on benefits other than predicting health problems, you will have the greatest impact on your team.

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9. Bahr, R., Clarsen, B., & Ekstrand, J. (2018). Why we should focus on the burden of injuries and illnesses, not just their incidence. British journal of sports medicine, 52(16), 1018–1021. https://doi.org/10.1136/ bjsports-2017-098160 10. López-Valenciano, A., Raya-González, J., Garcia-Gómez, J. A., Aparicio-Sarmiento, A., Sainz de Baranda, P., De Ste Croix, M., & Ayala, F. (2021). Injury Profile in Women’s Football: A Systematic Review and Meta-Analysis. Sports medicine (Auckland, N.Z.), 51(3), 423–442. https://doi.org/10.1007/s40279-020-01401-w 11. López-Valenciano, A., Ruiz-Pérez, I., Garcia-Gómez, A., Vera-Garcia, F. J., De Ste Croix, M., Myer, G. D., & Ayala, F. (2020). Epidemiology of injuries in professional football: a systematic review and metaanalysis. British journal of sports medicine, 54(12), 711–718. https://doi. org/10.1136/bjsports-2018-099577 12. Alahmad, T. A., Kearney, P., & Cahalan, R. (2020). Injury in elite women’s soccer: a systematic review. The Physician and sportsmedicine, 48(3), 259–265. https://doi.org/10.1080/00913847. 2020.1720548

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21. Ripley NJ, Cuthbert M, Ross S, Comfort P, McMahon JJ. The Effect of Exercise Compliance on Risk Reduction for Hamstring Strain Injury: A Systematic Review and Meta-Analyses. IJERPH. 2021 Oct 27;18(21):11260. 22. Gronwald T, Klein C, Hoenig T, Pietzonka M, Bloch H, Edouard P, et al. Hamstring injury patterns in professional male football (soccer): a systematic video analysis of 52 cases. Br J Sports Med. 2022 Feb;56(3):165–71. 23. Suarez‐Arrones L, Nakamura FY, Maldonado RA, Torreno N, Di Salvo V, Mendez‐Villanueva A. Applying a holistic hamstring injury prevention approach in elite football: 12 seasons, single club study. Scand J Med Sci Sports. 2021 Apr;31(4):861–74. 24. Osborne JW. Best practices in data cleaning: a complete guide to everything you need to do before and after collecting your data. Thousand Oaks, Calif: SAGE; 2013. 275 p. 25. Bahr R. Why screening tests to predict injury do not work—and probably never will…: a critical review. Br J Sports Med. 2016 Jul 1;50(13):776–80.

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PERSONALISING FEMALE FOOTBALLER HORMONE HEALTH FEATURE / DR NICOLA KEAY in a way to support optimal health and performance. However, as every woman has individual timing, concentrations and biological response to female hormones, a personalised approach is required. Nevertheless, taking daily blood samples to assess female menstrual hormones is neither practical nor financially feasible. Dr. Nicky Keay BA, MA, MB, BChir (Cantab),MRCP Sports and Dance Endocrinologist Honorary Clinical Lecturer Medicine, University College London Honorary Fellow Dept Sport and Exercise Sciences, Durham University CMO Forth Edge

1. Introduction Relative energy deficiency in sport (RED-S) was first described in the 2014 International Olympic Committee consensus statement . RED-S compromises the interrelated adverse clinical outcomes of low energy availability on both health and performance. Therefore, early identification of athletes at risk of RED-S is a priority as a prevention strategy . In female athletes, disruption of female hormone networks is an early indicator of the risk of developing RED-S. Although RED-S may be perceived as a situation only occurring in aesthetic or weight dependent sports, evidence is emerging that this syndrome can arise in other sports, including football.

Artificial intelligence techniques are used in many areas of medicine to personalise healthcare . These techniques allow clinicians to gain the maximal value from the minimum amount of data. Capillary blood sampling at two key time points during the menstrual cycle, allow hormone fluctuations to be modelled and compared to data from ovulating women with the same cycle length. In this way any disturbance of menstrual cycle hormones for an individual athlete can be identified. When combined with reported well-being metrics, this provides a personalised hormone health report . •

Female football specific energy availability questionnaire (FFEAQ) In terms of screening questionnaires for RED-S, there is a low energy availability female athlete questionnaire (LEAFQ) . However, this questionnaire is not sports specific and does not provide psychological indicators of athletes potentially at risk of developing RED-S. Published sport specific questionnaires for cyclists and dancers, with a scoring system have proved useful clinical tools . A similar approach was used to develop the female football specific energy availability questionnaire (FFEAQ) .

2. Early identification of female players at risk of RED-S •

Modelling of female hormones over the menstrual cycle Healthy hormone network function is key to athletic performance. Hormones are impacted by athlete behaviours around training load, nutrition, and recovery. Imbalances in behaviours, whether intentional or unintentional, influence hormone networks. For example, low energy availability resulting because of a mismatch between energy intake and energy expenditure, can cause a subtle subclinical hormone dysfunction. In the case of female athletes this can be due to subclinical anovulatory cycles . This means that although an athlete reports regular having a regular menstrual cycle, her hormones may not be fluctuating

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To ensure female football players attain optimal health and performance and avoid developing the adverse outcomes of RED-S, the following monitoring strategies of personal player health are suggested: • •

Modelling of female hormones over the menstrual cycle Female football specific energy availability questionnaire (FFEAQ)

3. Practical solutions for personalising female hormone health • Modelling female hormones Capillary sampling at 2 points during the menstrual cycle is not too onerous for athletes and can be sent in the post for analysis at a UK accredited laboratory. Once the results are available and have been entered into the model, personalised reports can be generated before the next menstrual cycle starts thus providing rapid feedback to the female athlete. Although the study population number was small (in view of the challenges of a pandemic on research), there was evidence of subclinical anovulatory cycles, which may have otherwise been undetected. In a larger longitudinal study of professional dancers, evidence for this type of subtle effect of low energy availability on female hormone function was found using this methodology . This is of clinical significance for all female athletes as there is increasing evidence that subclinical anovulatory cycles have adverse effects of health and consequently performance .

football medicine & performance

Personalising Female Athlete Hormone Health Menstrual and Hormone Status Eumenorrhea Healthy hormones

Subclinical anovulatory cycles Subtle hormone disruption

Amenorrhoea Hormone down regulation

Football-specific Energy Availability Questionnaire (FEAQ) Score

Dr Nicky Keay nickykeayfitness.com

•

Female football specific energy availability questionnaire (FFEAQ) The FFEAQ is a practical, low-cost tool to identify players with indicators of low energy availability and at risk of progression to RED-S. Although the 22 football players in our study recorded more positive scores and lower risk of RED-S than professional dancers, nonetheless 5 players reported previous secondary amenorrhoea. Early identification of subtle warnings signs in athletes is far better than waiting until presentation with a clinically significant adverse outcome of RED-S. This facilitates an effective prevention method when combined with personalised hormone monitoring and the opportunity to be proactive in supporting individual player health and performance. Healthy individual players mean a stronger, more successful team. 4. Conclusions Key points for the football medicine and performance community • Early identification of female players at risk of relative energy deficiency in sports (RED-S) is key in prevention before the development of overt adverse impacts on health and performance • The female football low availability questionnaire (FFEAQ) and close monitoring of female hormone networks are effective strategies in picking up the early warning signs of risk of RED-S

•

Reliable information sources such as www.health4performance.co.uk from British Association of Sport and Exercise Medicine is a useful resource for players, coaching and healthcare staff Online courses for female athletes and their coaches endorsed by British Association of Sport and Exercise Medicine are another resource https://www. sportreadyacademy.com/p/trainingas-a-high-performing-femaleathlete1/?preview=logged_out

Key take home messages • Healthy hormone networks are essential for athlete health and performance • Imbalances in athlete behaviours can have adverse effects on hormone networks and lead to RED-S • Close monitoring of female hormone networks is key in personalising strategies for optimal health and performance in female footballers

5. Acknowledgements We would like to thank the athletes, staff, and the club for their participation in this research.

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Mountjoy M, Sundgot-Borgen J, Burke L et al The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S) British Journal of Sports Medicine 2014;48:491-497. Keay N, Francis G Infographic. Energy availability: concept, control and consequences in relative energy deficiency in sport (RED-S) British Journal of Sports Medicine 2019;53:1310-1311. Moss S, Randell R, Burgess D, et al. Assessment of energy availability and associated risk factors in professional female soccer players. European Journal of Sport Science 2020, 1–27. https://doi.org/10.1080/17461391.2020.1788647 Passing on the exercise baton: what can endocrine patients learn from elite athletes? Endocrine health with exercise Clinical Endocrinology 2022 https://onlinelibrary.wiley.com/doi/10.1111/ cen.14683 “Machine learning for individualised medicine” Mihaela van der Schaar, Annual Report of the Chief Medical Officer. 2018, Chapter 10. Health 2040 – Better Health Within Reach. Accessed 2021 Keay N. Hormone Intelligence for Female Dancers, Athletes and Exercisers British Journal of Sports Medicine blog 2021 https:// blogs.bmj.com/bjsm/2021/06/28/hormone-intelligence-forfemale-dancers-athletes-and-exercisers/ Melin A, Tornberg AB, Skouby S et al. The LEAF questionnaire: a screening tool for the identification of female athletes at risk for the female athlete triad. Br J Sports Med. 2014 Apr;48(7):540-5. doi: 10.1136/bjsports-2013-093240. Epub 2014 Feb 21. PMID: 24563388. Keay N, Overseas A, Francis G Indicators and correlates of low energy availability in male and female dancers BMJ Open Sport & Exercise Medicine 2020;6:e000906. doi: 10.1136/ bmjsem-2020-000906 Nicola Keay, Eddie Craghill, Gavin Francis. Female football specific energy availability questionnaire and menstrual cycle hormone monitoring MedRxiv 2021 https://doi. org/10.1101/2021.10.29.21265667 Nicola Keay, Martin Lanfear, Gavin Francis. Clinical application of monitoring indicators of female dancer health, including application of artificial intelligence in female hormone networks medRxiv 2021.09.27.21264119; doi: https://doi. org/10.1101/2021.09.27.21264119 Liu A.Y., Petit M.A., Prior J.C. Exercise and the Hypothalamus: Ovulatory Adaptations. In: Hackney A., Constantini N. (eds) Endocrinology of Physical Activity and Sport. Contemporary Endocrinology. Humana, Cham 2020. https://doi.org/10.1007/9783-030-33376-8_8

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FUELLING FOR THE WORK REQUIRED IN PROFESSIONAL FOOTBALL: A THEORETICAL MODEL FOR CARBOHYDRATE PERIODISATION FEATURE / DR LIAM ANDERSON Introduction Professional football clubs are continuously posed with new questions that can often be answered through research and development. Whilst it is important to stay in tune with current literature to help answer these questions, it is also important to ask and answer questions that are specific to individual environments (i.e., players, management styles, training times, operating restrictions etc.). Going back almost 10 years, the questions we had before embarking on this research were “how much do these players need to eat each day?” and “what does players nutritional intake look like in comparison to recommended guidelines?”. We set about performing numerous investigations into the physical loading, energy expenditure and energy intake of professional football players with the end goal of being to provide more sophisticated nutritional programmes to meet energy expenditure and facilitate improvements in performance, recovery, and fitness adaptations. Energy expenditure is a critical variable in human health and physiology 1, and implementing strategies to meet energy demands within elite football can be crucial for success and overall health of the player. Given that daily protein recommendations range from 1.6-2.2 g.kg-1 and recommended fat intakes equivalent to 30% energy intake 2, manipulation of carbohydrate intake would allow football players to meet differing daily energy demands. This type of periodised carbohydrate approach to sports nutrition has gained significant attention in endurance sports in recent years 3. Indeed, as part of answering the research questions mentioned above, our group and others have researched professional soccer players physical loading and energy requirements 2, 4-7 . These new findings have significantly altered the approach that performance practitioners follow when providing training and nutritional recommendations. The following article will summarise a theoretical model based off current scientific understanding of physical loading, energy expenditure and energy intake 8. This model, where carbohydrate is adjusted day-by-day and meal-by-meal according to the upcoming activity and the desired outcome of training sessions i.e., promoting exercise intensity vs stimulating metabolic adaptations, has been translated as a “fuel for the work required”

Figure 1: Playing squad average total distance completed in training sessions and matches during two different 7-day testing periods. Figure A = one game week, Figure B = three game week (games played with <72 hours apart) Red bars = matches and green bars = training. MD = Match day. a denotes difference from day MD-4, b denotes difference from day MD-3, c denotes difference from day MD-2, d denotes difference from day MD-1 and e denotes difference from MD+2/ -1, all P < 0.05. Figure adapted and redrawn from Anderson et al. 4.

model. Although this is a model that can be implemented into many football clubs, it is important to tailor to the individual training structure and demands (i.e., morning training vs. evening training, high vs. low demands on different days etc.). Carbohydrate requirements for performance Match demands have been widely accepted by practitioners and academics since the 1970s 9. These demands have increased over time with distances covered at high-speed increasing ~30% from 2006-07 to 2012-13 in the English Premier League (EPL) and ~9% from 2012-13 to 2019-20 in the Spanish La Liga, heightening the importance of nutritional preparation for match play 10, 11. From a metabolic perspective,

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muscle glycogen is the major energy source to fuel these match demands. Krustup et al. 12 observed that pre-game muscle glycogen was 449 ± 23 mmol. kg-1 dry weight and decreased to 225 ± 23 mmol.kg-1 dry weight immediately after the match. This would suggest that there was sufficient glycogen available to continue exercising, however, analysis of individual muscle fibre (i.e., type IIa and IIx fibres) revealed that 50% of fibres could be classified as empty or almost empty. These fibres are responsible for sprinting and high-intensity activity. Therefore, muscle and liver glycogen are a potential contributing factor to fatigue and reduction in high intensity running towards the end of matches.

football medicine & performance

Given the role of muscle glycogen promoting high-intensity intermittent exercise performance 13, 14, professional players should aim for high glycogen stores for a 24-hour period the day prior to match play 15. Daily intakes in this period should equate to 6-8 g.kg-1 to maximise their glycogen stores. This is providing that training intensity and duration is significantly reduced the day before match play (see Figure 1). In an analysis into players from the English Premier League we found players only consumed 4 g.kg-1 the day before a game (MD-1) 5. Such values have shown reduced total distance covered on match day compared with 8 g.kg-1 16. Therefore, practitioners should be aware that MD-1 is a potential area where players can improve their current practise. If players have correctly loaded muscle glycogen on the day prior to the game, they should arrive at the pre match meal with the goal to promote liver glycogen storage prior to match play. This is more evident in kick offs that are in the early afternoon or morning given that liver glycogen can be depleted by as much as 50% after an overnight fast and may not fully recover until early evening 17. The timing of this meal changes according to kick off time it is recommended that this meal be consumed 3-4 hours before kickoff and contain 1-3 g.kg-1 of carbohydrates. Professional players from the EPL reported intakes of 1-1.5 g.kg-1 in the pre-match meal, values that may be suboptimal for performance when considered with insufficient carbohydrate intakes the day prior to match play 6. Carbohydrate feeding during exercise is likely to improve elements of match day performance when fed at a rate of 3060g.hr-1 18, 19. Ingestion of carbohydrates at this rate improves physical performance 20, 21 as well as technical actions 22, 23. Such rates of ingestion correspond to carbohydrate intake at the beginning (20-30g) and end of the warmup period (20-30g), the half-time period (2040 g) and if possible, the second half (20-30g). This strategy has not been experimentally tested and players should refine their individual strategy during training and friendly games. Similar to other aspects of carbohydrate intake for performance, players from the EPL do not readily achieve in-game carbohydrate guidelines and are certainly areas that can be addressed to further fuel for the demands of match play 6.

re-synthesis 24. It is important to note that this should begin immediately after match play (i.e., in the changing room or on the bench after coming off as a substitute) as this is when the muscle is most receptive to glucose uptake and glycogen synthesis 25. In addition, to promote liver glycogen resynthesis ingestion of sucrose over glucose prevails 26 . Such data suggests that fructose containing foods and drinks would be beneficial in acute recovery from match play. Despite the clear evidence and benefits of this type of carbohydrate feeding for optimising muscle and liver glycogen resynthesis, this is a key area for improvement in many professional players. For example, when recovering from an 8:15 pm kick off EPL players reported <1 g.kg-1h-1 in the initial 2 h recovery period whilst carbohydrate intake in similar timescales at the 4:15 pm kick off increased to 1-1.5 g.kg-1h-1 6 . Whilst the reasons for this aren’t definitive, provisions are required to be put into place for players during such scenarios to obtain optimal recovery from match play (i.e., recovery pack or postmatch team meal). Muscle glycogen can take up to 24-72 h after exercise to completely replenish after match play, therefore there is a requirement to consume adequate carbohydrate intake on the day(s) after the match. Players should be aware of this even if the day following match play is a day off or with reduced time within the club due to only performing recovery exercises. In the example of EPL players carbohydrate intakes in the days following match play were ~4 g.kg-1 5. Intakes as low as this would be considered insufficient in facilitating

glycogen resynthesis as it took cohorts of Danish 2-3 days to fully recover after 6-9 g.kg-1 carbohydrate intake 27, 28. This clearly highlights the requirement for high carbohydrate intake for recovery from match play, in particular when time between matches is limited (i.e., congested fixture periods; see Figure 1). Carbohydrate requirements of soccer training In contrast to the match demands, typical training loads of soccer players have only recently been examined with a variety of metrics now common place in the literature and used within the applied environment 8. A review of the current available literature identifies that absolute training loads are not near as high as experienced in match play with the highest load being performed in the middle of the week (i.e., MD-4, MD-3; see Figure X). Unlike match play (and potentially due to the highly variable demands), the glycogen cost of actual training sessions has not yet been studied. In a soccer-simulated training protocol, Jeong et al. 29 reported glycogen depletion of only 20%. Although this protocol is limited due to the omission of technical actions and changes of direction etc. Such data considered in combination with real-world training load data suggest that the glycogen cost of training is not near that of match play. Therefore, the principle of “fuelling for the work required” from endurance sports, where carbohydrate intake is adjusted on a day-by-day and meal-by meal manner according to the metabolic demands of the upcoming training sessions seems a relatable model for professional football players 3.

Carbohydrate requirements for recovery It is generally accepted that acute muscle glycogen re-synthesis requires players to consume 1.2 g.kg-1h-1 of high glycaemic carbohydrate for 3-4 hours to optimally facilitate short-term glycogen

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football medicine & performance

The rationale for the development of carbohydrate periodisation strategies is further enhanced on the premise that commencing and/or recovering from exercise with reduced carbohydrate availability up-regulated cell signalling pathways that regulate oxidative adaptations of human skeletal muscle 30, 31 , the result of which may culminate in enhanced training adaptations and improved exercise performance. It is noteworthy that professional players tend to already adopt a form of carbohydrate periodisation across the weekly microcyle. For example, we observed intakes of 4 g.kg-1 on training days and X g.kg-1 on match days in EPL players 5. These data are comparable with Dutch Eredivisie Players 7. Additionally, utilising the gold standard for assessing free living energy expenditure, the energy expenditure of professional players are approximately 3000-3500 kcal.d-1, equivalent to ~4855 kcal.kg-1 lean body mass 6, 7. Given that daily protein recommendations (i.e., 1.6-2 g.kg-1) and recommended fat intakes equivalent to 30% of total energy intake 2, it is reasonable to suggest that average daily carbohydrate 1. Pontzer H, Yamada Y, Sagayama H, et al. Daily energy expenditure through the human life course. Science 2021; 373: 808-812. DOI: 10.1126/science.abe5017. 2. Collins J, Maughan RJ, Gleeson M, et al. UEFA expert group statement on nutrition in elite football. Current evidence to inform practical recommendations and guide future research. Br J Sports Med 2021; 55: 416. 20201023. DOI: 10.1136/ bjsports-2019-101961. 3. Impey SG, Hammond KM, Shepherd SO, et al. Fuel for the work required: a practical approach to amalgamating trainlow paradigms for endurance athletes. Physiol Rep 2016; 4. DOI: 10.14814/phy2.12803. 4. Anderson L, Orme P, Di Michele R, et al. Quantification of training load during one-, two- and three-game week schedules in professional soccer players from the English Premier League: implications for carbohydrate periodisation. J Sports Sci 2016; 34: 1250-1259. 2015/11/05. DOI: 10.1080/02640414.2015.1106574. 5. Anderson L, Orme P, Naughton RJ, et al. Energy Intake and Expenditure of Professional Soccer Players of the English Premier League: Evidence of Carbohydrate Periodization. Int J Sport Nutr Exerc Metab 2017; 27: 228-238. 2017/01/05. DOI: 10.1123/ijsnem.2016-0259. 6. Anderson L, Naughton RJ, Close GL, et al. Daily Distribution of Macronutrient Intakes of Professional Soccer Players From the English Premier League. Int J Sport Nutr Exerc Metab 2017; 27: 491-498. 20170628. DOI: 10.1123/ijsnem.2016-0265. 7. Brinkmans NYJ, Iedema N, Plasqui G, et al. Energy expenditure and dietary intake in professional football players in the Dutch Premier League: Implications for nutritional counselling. J Sports Sci 2019; 37: 2759-2767. 20190216. DOI: 10.1080/02640414.2019.1576256. 8. Anderson L, Drust B, Close GL, et al. Physical loading in professional soccer players: Implications for contemporary guidelines to encompass carbohydrate periodization. J Sports Sci 2022; 40: 1000-1019. 20220306. DOI: 10.1080/02640414.2022.2044135.

intakes of 3-6 g.kg-1 during training days (that are not aligned to MD-1 or MD+1) would be sufficient to meet daily energy requirements that encompass the typical range in daily training intensity and duration associated with in season training schedules. Practical carbohydrate periodisation strategy Based on the fuel for the work required approach and assessments of energy expenditure in professional players, we provide a theoretical overview of day-by-day and meal-by-meal carbohydrate intakes in both a 1 game week (see Table 1) and 2 game week scenario (see Table 2). This model intends to provide players who partake in a “morning” training session and only one on field session per day. Both weeks have the aim of facilitating performance and recovery with nutritional strategies in the 1-game week also aiming to augment fitness adaptations during training days. It is also of note that this strategy is for adult male players who play a significant portion (i.e., >60 minutes) of match play and are involved in every training session. If players are not receiving significant match minutes and/ or are not involved in all training

sessions, then training and nutritional strategies are to be revised. Conclusion Professional football clubs should aim to answer their own performance questions to evolve and develop practises. It is important to set out on a journey to answer these questions in a thorough but efficient manner. Presented in this article are some theoretical nutritional guidelines that operate on a day-by-day and meal-by-meal approach to carbohydrate feeding in both a 1 and 2 game week. Although this theoretical model is based on scientific understanding, it should be tested in both in the applied and laboratory environments. Practitioners may also tweak the model to suit their own individual scenarios (i.e., rest day in the middle of the week and/ or evening training sessions). Acknowledgements It is important to acknowledge Professors James Morton, Barry Drust and Graeme Close in the creation of the published manuscript 8. Although they weren’t directly involved in the creation of this article, they were integral for the completion of the publication.

11. Lago-Penas C, Lorenzo-Martinez M, Lopez-Del Campo R, et al. Evolution of physical and technical parameters in the Spanish LaLiga 2012-2019. Sci Med Footb 2022: 1-6. 20220307. DOI: 10.1080/24733938.2022.2049980.

23. Russell M, Benton D and Kingsley M. Influence of carbohydrate supplementation on skill performance during a soccer match simulation. J Sci Med Sport 2012; 15: 348-354. 20120109. DOI: 10.1016/j.jsams.2011.12.006.

12. Krustrup P, Mohr M, Steensberg A, et al. Muscle and blood metabolites during a soccer game: implications for sprint performance. Med Sci Sports Exerc 2006; 38: 1165-1174. DOI: 10.1249/01.mss.0000222845.89262.cd.

24. Burke LM, van Loon LJC and Hawley JA. Postexercise muscle glycogen resynthesis in humans. J Appl Physiol (1985) 2017; 122: 1055-1067. 20161027. DOI: 10.1152/ japplphysiol.00860.2016.

13. Balsom PD, Wood K, Olsson P, et al. Carbohydrate intake and multiple sprint sports: with special reference to football (soccer). Int J Sports Med 1999; 20: 48-52. DOI: 10.1055/s-2007-971091.

25. Ivy JL, Katz AL, Cutler CL, et al. Muscle glycogen synthesis after exercise: effect of time of carbohydrate ingestion. J Appl Physiol (1985) 1988; 64: 1480-1485. DOI: 10.1152/ jappl.1988.64.4.1480.

14. Saltin B. Metabolic fundamentals in exercise. Med Sci Sports 1973; 5: 137-146. 15. Bussau VA, Fairchild TJ, Rao A, et al. Carbohydrate loading in human muscle: an improved 1 day protocol. Eur J Appl Physiol 2002; 87: 290-295. 20020528. DOI: 10.1007/s00421-002-0621-5. 16. Souglis AG, Chryssanthopoulos CI, Travlos AK, et al. The effect of high vs. low carbohydrate diets on distances covered in soccer. J Strength Cond Res 2013; 27: 2235-2247. DOI: 10.1519/ JSC.0b013e3182792147. 17. Iwayama K, Tanabe Y, Tanji F, et al. Diurnal variations in muscle and liver glycogen differ depending on the timing of exercise. J Physiol Sci 2021; 71: 35. 20211121. DOI: 10.1186/s12576-021-00821-1. 18. Baker LB, Rollo I, Stein KW, et al. Acute Effects of Carbohydrate Supplementation on Intermittent Sports Performance. Nutrients 2015; 7: 5733-5763. 20150714. DOI: 10.3390/nu7075249. 19. Russell M and Kingsley M. The efficacy of acute nutritional interventions on soccer skill performance. Sports Med 2014; 44: 957-970. DOI: 10.1007/s40279-014-0184-8. 20. Rodriguez-Giustiniani P, Rollo I, Witard OC, et al. Ingesting a 12% Carbohydrate-Electrolyte Beverage Before Each Half of a Soccer Match Simulation Facilitates Retention of Passing Performance and Improves High-Intensity Running Capacity in Academy Players. Int J Sport Nutr Exerc Metab 2019; 29: 397-405. 20190701. DOI: 10.1123/ ijsnem.2018-0214.

9. Reilly T and Thomas V. A motion analysis of work-rate in different positional roles in professional football match-play. Journal of Human Movement Studies 1976; 2: 87-97.

21. Harper LD, Stevenson EJ, Rollo I, et al. The influence of a 12% carbohydrate-electrolyte beverage on self-paced soccer-specific exercise performance. J Sci Med Sport 2017; 20: 1123-1129. 20170421. DOI: 10.1016/j.jsams.2017.04.015.

10 . Barnes C, Archer DT, Hogg B, et al. The evolution of physical and technical performance parameters in the English Premier League. Int J Sports Med 2014; 35: 1095-1100. 20140710. DOI: 10.1055/s-0034-1375695.

22. Currell K, Conway S and Jeukendrup AE. Carbohydrate ingestion improves performance of a new reliable test of soccer performance. Int J Sport Nutr Exerc Metab 2009; 19: 34-46. DOI: 10.1123/ ijsnem.19.1.34.

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26. Fuchs CJ, Gonzalez JT, Beelen M, et al. Sucrose ingestion after exhaustive exercise accelerates liver, but not muscle glycogen repletion compared with glucose ingestion in trained athletes. J Appl Physiol (1985) 2016; 120: 1328-1334. 20160324. DOI: 10.1152/japplphysiol.01023.2015. 27. Gunnarsson TP, Bendiksen M, Bischoff R, et al. Effect of whey protein- and carbohydrate-enriched diet on glycogen resynthesis during the first 48 h after a soccer game. Scand J Med Sci Sports 2013; 23: 508-515. 20111123. DOI: 10.1111/j.16000838.2011.01418.x. 28. Krustrup P, Ortenblad N, Nielsen J, et al. Maximal voluntary contraction force, SR function and glycogen resynthesis during the first 72 h after a high-level competitive soccer game. Eur J Appl Physiol 2011; 111: 2987-2995. 20110330. DOI: 10.1007/s00421-011-1919-y. 29. Jeong TS, Bartlett JD, Joo CH, et al. Acute simulated soccerspecific training increases PGC-1alpha mRNA expression in human skeletal muscle. J Sports Sci 2015; 33: 1493-1503. 20141223. DOI: 10.1080/02640414.2014.992937. 30. Morton JP, Croft L, Bartlett JD, et al. Reduced carbohydrate availability does not modulate training-induced heat shock protein adaptations but does upregulate oxidative enzyme activity in human skeletal muscle. J Appl Physiol (1985) 2009; 106: 1513-1521. 20090305. DOI: 10.1152/ japplphysiol.00003.2009. 31. Bartlett JD, Hawley JA and Morton JP. Carbohydrate availability and exercise training adaptation: too much of a good thing? Eur J Sport Sci 2015; 15: 3-12. 20140619. DOI: 10.1080/17461391.2014.920926.

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IMPORTANCE OF SLEEP FOR ELITE FOOTBALLERS FMPA PODCAST / This is a transcript of the FMPA Podcast episode of the same name that was released in October 2021. If you’d prefer to listen, all episodes can be found on the FMPA website, SoundCloud and Spotify. In this podcast episode host Eleanor (Elle) Trezise, medical student and member of the FMPA Education Team, speaks to Anna West who is a Sleep, Recovery and Well-Being Specialist working with Brentford FC and Founder of Sleep2Perform. It was transcribed by the host.

Elle Trezise: Welcome to this Football Medicine and Performance Podcast. I am Elle Trezise, a medical student in London and your host for today’s episode. Today I am delighted to be joined by Anna West. Anna West is a Sleep, Recovery and Well-Being specialist working with Brentford FC and Founder of Sleep2Perform, a high-performance consultancy who specialise in sleep and recovery, and work with leading sports teams and businesses.

Anna West: Well, let’s hope that I will be able to deliver some magical words. But just remember that when it comes to sleep, there’s no general recipe on how you can do it best.

Thank you for joining us today, Anna.

Anna West: So, I have a background in sports science and I’m also a nurse, and that in itself is a pretty strange combination. I was very lucky. So, straight out of university I was lucky to get a job in a medical technical company that was specialised in sleep and used the first many years of my career path to actually work in this company, specialised in sleep, heavily involved in sleep research projects across Europe and in the US.

Anna West: Thank you very much for the invitation and for that nice introduction. Elle Trezise: Good to have you on board. So today we’re going to discuss how to support elite footballers with their sleep and recovery. I’m sure this will be of great interest to our listeners and that we’re going to be able to learn a lot from you.

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Elle Trezise: So, tell us a little bit about your career to date. What got you interested in sleep, recovery and well-being in elite athletes?

And then back in 2015 some changes were coming up in this company and I knew that the point that I loved to work with was the

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consultancy part, and I had at that time already done quite a lot of projects in elite sports in relation to sleep. So, I decided to start on my own and have worked with sleep in elite sports settings ever since. Elle Trezise: That’s really interesting. So why is sleep important for optimal athletic performance? And also, how does it compare to other methods that elite athletes might use to help their recovery? Anna West: I mean, to be fair, without putting sleep on a pedestal, right, sleep is by far the most important ground stone in athletic performance because it’s the pre-condition of creating success in basically any other domain surrounding the athlete. If you don’t sleep well or if the quality of the sleep that you’re getting is not high, it will have impact on your nutritional status. It will have impact on your performance ability. It can be measured on various factors like sprinting time, decision making and so forth. But it also has a high impact on the emotional/psychological side: your motivation, your stability when it comes to emotions and so forth. Your ability to step on the brake when you have to, but also to hold yourself back when you have to. So, sleep is a huge impactor. But quite often, we don’t regard sleep as the pre-condition. We regard sleep as something that we just do - a little bit of a no brainer. We all know that sleep is needed. But very often athletes don’t really see it as an investment area and a lot of things would change if they actually did. Elle Trezise: So, I noticed you used the word “precondition” there. I think I get what you mean but do you mind just clarifying exactly what you mean by that?

during the sleep. A good example would be that it is where you balance your hunger hormones. So, if you’re not sleeping well, you will overproduce the hormone that makes you hungry. You will underproduce the hormone that makes you feel full. So, if you’re doing a nutritional intervention, sleep will be a pre-condition in order for that nutritional intervention to be successful because if you’re not sleeping you will have a misbalance in your hormones.

I always look for markers in relation to sleep apnoea, as an example, restless leg syndrome and so forth. I don’t meet it very often.

Elle Trezise: So, it really sounds like you’re saying that sleep is an absolute cornerstone of a lot of aspects of optimal athletic performance which is why it’s so important.

Elle Trezise: So, it’s a really good time for me to ask you about the scenario that you’ve started working with a new team. You’re told at least a few individuals, for example, are known to struggle with their sleep. So, what would you do in this situation?

Anna West: Completely agree. It definitely is but the approach to sleep and the understanding of sleep was maybe in the past not regarded exactly like this. You also have the opposite view, right? The warrior who can just crack on without having as many hours of sleep as his neighbour and so forth. But what we’ve seen over time, also from an illnesses statistical perspective is that that over time, sleep has become a cornerstone in a lot of health diseases as well. So, we know that poor sleep is linked to an increased risk of heart diseases, development of cancer and so forth. So, it’s not only related to athletic performance, but it’s related to overall health. Elle Trezise: What about sleep issues in athletes? Are they common? And if so, why?

Anna West: So, the word “pre-condition” from my point of view is meant as sleep being needed. You need to have sleep. You need to have a certain amount of hours and you need to have a certain amount of quality in your sleep in order for your physiology to work. Hence why sleep becomes this pre-condition.

Anna West: I see quite a lot of athletes with problems. What you see less among athletes is sleep diagnostics that need treatment, right? So, you will see in certain sports athletes with sleep apnoea, but it’s very often related to the sports where the athletes would have a big neck size or have a high BMI. Whereas in football - and we’re discussing football here - the prevalence of sleep issues requiring sleep diagnostic treatment is actually not very high.

Without going into massive details about the physiology of sleep, there are a lot of different physiological aspects which are undertaken

For the last five years I always - when I engage and I work with football players - I usually do an initial screening on them and

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What I very often meet would be insomniarelated issues. Athletes that simply can’t fall asleep due to high pressure due to congested scheduling, travel demands and so forth which are all in theory markers that can be turned around by applying different mythology, by applying sleep hygiene factors but not diagnostic treatment.

Anna West: To be fair, I’m actually quite data driven, right? I see myself as a person founded in science and then I know that I’m very pragmatic when I have to work with sleep in a daily setting. So, what I always do is that I conduct the screening and my screening mythology is basically a screening tool that I’ve used the past five/six years to develop for my company Sleep2Perform. So, if you look into to the scientific world, you will find a lot of validated questionnaires that you can use to screen people for sleeping disorders. You can have questionnaires which have been validated for the normal population. In the past years, a few questionnaires also came out and have been validated in the athletic environment. What I do is that I’ve actually merged quite a lot of these questionnaires into one because I regard a football player as a person, as a human being, and not just someone who is delivering his performance in an athletic setting, right? They leave the training ground, they go home, they might have things in their private lives that would be obstructive to sleep as well. So, what I do is that I always use the same screening tool and I don’t do work with anyone, whether it’s a football player or any other athletes, without conducting the screening. Once I’ve conducted the screening, I profile the player in a quite simple traffic light: yellow, green or red player. Dependent on the challenges that I will find in the screening and then from that point on, it’s pretty different depending on environment and who I’m working with. I work both with individual clients which could be individual players from a variety of clubs, but I also work on a

FMPA podcast club level. Usually when I then conduct the screening, based on the data that I get out of that screening, I do some educational workshops back to the players which will be then created content wise purely on their data because environments and teams can be very different. So, let’s say that I’m working with a very young team. The sleep challenges might be… If I’m working with a team where the squad is composed by older players, it’s not only sleep deprivation caused by the player himself, but it might be related to small children and so forth. So, the education that I try to embed always regards who I’m talking to and then based on input from the club, and so forth, I tend to work as well with the players on an individual basis.

board everything you’ve said about sleep hygiene techniques, and all this sort of stuff. They’re really trying, but they’re still struggling with their sleep. They might even be starting to consider, you know, whether they want to even try sleep medication. What would you do at this stage? Anna West: To be fair, I’m always preaching against sleep medication, but I think it’s important to - before we just like group sleep medication as one - to discuss what type of sleep meditation you’re talking about. Because if you’re talking melatonin, it’s one thing. If you’re talking like heavy sleeping drugs, it’s addictive, right? So, and again, it also relates very much back to the situation.

Usually, I say I don’t work with players for less than four months at a time because my aim when I am working with the player is not only to create results but to create sustainable results. So that the way and the mythology that I am applying is not just going to convert some negative sleep history and sleep data into something positive, but that we are creating patterns that will stay with the player over time as well. Usually when you work with players for a minimum of four months, you also see the fluctuation of the season.

I always work against any type of external pharmaceutical support. Unless everything else has been completely excluded. If that makes sense? You’ve tried basically everything. I don’t very often encounter the situation where we have to end up using sleeping medication. I very often try the opposite… I get to work with players because they have been - due to their poor sleeping status - using sleeping medication for quite some time and we kind of try to revert that negative pattern.

Elle Trezise: Yeah. So, when you talk about the fluctuation of the season, I suppose, going back to what you were talking about (some of the factors that affect sleep), are you referring to, you know, fixture congestion, international breaks and how [they] can [lead to] jet lag and so on?

Elle Trezise: So, I just wanted to ask a follow up question on what you were saying about educating athletes. I was just wondering, what ways have you found to be effective to educate the athletes, for example, you know, a group chat in a room with a presentation or one-to-one meetings? How does it work?

Anna West: Yes, exactly. I mean, compare this season to last season and then compare last season to the previous season, right? It’s been very different seasons.

Anna West: I don’t have a standardised way of doing it and I think again it comes very much down to the environment.

So last year we had a pandemic situation, a lot of unpredictability, congested scheduling, then they didn’t play, then all of a sudden, they had to play a lot more games than they were used to. This season is still affected by the pandemic as well to a degree. We don’t know if people will be isolated and so forth. I always try to embed these unpredictable factors into my mythology. Elle Trezise: Just continuing on with that scenario. So, let’s say that you’ve got an individual or few individuals and they’ve taken on

What I think is always important to keep in the back of your mind is that sleep is a pretty vulnerable subject, and there are a lot of reasons to why individuals are unable to sleep. Sometimes it’s very much related to group dynamics at the club. Let’s say you have a very top-down run environment with a lot of pressure and so forth. If you want the player to acknowledge and to see where the sleep challenges might come from, and then you’re in a room where the head coach is actually also in the room when you’re giving that educational workshop,

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he might not come out of the bush and tell exactly why he’s unable to sleep. So, what I prefer often to do is actually to keep the workshops very player related. Of course, onboard the staffing members and so forth. But create this trustworthy environment where you can actually allow players to speak up, tell them why they’re compromising their sleep. But before that, you kind of need to give them some ammunition to why they should even invest in the area. Like, sleep isn’t just something that we do. It’s not, right? It has a lot of impact on you, on an athlete. They kind of need to understand and onboard these factors so that they learn to invest in sleep just as much as they would invest in any other performance parameter. So, one thing is, like, educating them to how to change it but they need to understand why as well. Look, if you tell any player that there’s a quite high link between injury risk and poor sleep, they will start to, you know, to buy into it. If you tell players, especially male players, that there’s a very high link between poor sleep and an underproduction of testosterone, and they understand that testosterone is pretty important both in male sexual behaviour but also in their ability to rebuild their muscles, suddenly it becomes this ammunition point where they actually want to onboard it because they see it as a part of their performance optimization pattern. Rather than something that they need to fix. Once they learn that sleep is a weapon, rather than something that they just do and that it can give them the margins that they’re all looking for and maybe the competitive advantage, you give them a reason to why they should invest in it. Elle Trezise: Yeah, so that’s really interesting. I think it’s a really key takeaway that essentially to get the players on board, if you can convince them it can enhance their playing ability and how much they can play and reduce the injury risk, then they’re going to be sold into it and then they ‘re more likely to get on board. Another question I have is, can nutrition impact sleep? Anna West: It’s a little bit of a bees’ nest area to discuss, right? Because there are a lot of opinions. My view on that question is that I trust that a balanced nutrition overall will lead to a higher sleep output. I think it’s quite misunderstood that you can eat certain nutrients just before

football medicine & performance you go to bed if the rest of your nutrition is poor, right? There is always a dilemma because we know that players usually would load carbohydrates on match day minus one (MD-1). Carbohydrates might not be the best thing to eat just before you go to bed but from a loading perspective it’s needed. So, you need to address nutrition pretty pragmatically when it comes to sleep, but that being said, you also need to address sleep pretty pragmatically so that it fits into an athletic setting. Because sleep science says one [thing], reality says something different. When it comes to nutrition, it’s a little bit the same and quite often a discussion about the hen and the egg, right? Protein enriched nutrition before going to bed has a proven impact on the sleep quality output. But if, again, a player needs to load carbohydrates prior to a match, maybe it’s better that he loads the carbohydrates on that MD-1 to get that output on the performance scale and then we would do, nutritional wise, something else on other days. Elle Trezise: So, you’ve talked about some of the actual macronutrients that might be good to have or not so good to have for sleep. What about timing of eating? Is there a certain period of time before bed, like, a time window when they should not be eating? Anna West: Look, a heavy meal before going to bed doesn’t do a footballer or anyone else any good because you’re basically putting gas on a fire that you want to turn off right? You don’t want to push your metabolism just before you go to bed. So that’s kind of, like, rule number one. I think what I encounter a lot more as being a problem is actually not nutrition as an isolated thing, but the inability to hydrate yourself well enough during the day or sufficiently during the day. So, a lot of players would have a tendency to neglect hydration during the day. But they all know that it is important. So, it quite often leads to a player drinking a lot of fluids [in] late afternoon/ evening which again then leads to a lot of visits to the toilet during the night because they’re over-hydrated. And if you go into sleep physiology, you being poor at hydrating yourself leads to a poor sleep quality because you will have more awakenings which then puts you in the injury risk zone, ultimately, because you’ve had unnecessary awakenings during the night breaking your own sleep cycle. So, nutrition should not be isolated from hydration.

We’re not dealing with 65-year-old men with a reason to go to the toilet many times during the night, right? They don’t have an enlarged prostate or anything like that. They’re healthy, young athletes. So, it’s normal to visit the toilet but it’s not normal to visit the toilet four/five times a night because you’re overhydrating in the afternoon/evening. Elle Trezise: I suppose with most things getting the balance right is key. Just focusing on hydration, if you drink too little that affects your sleep. If you drink too much that also affects your sleep. Anna West: But usually, I always say that a good night’s sleep starts when you wake up in the morning, right? So, you need to expose yourself to sunlight in the morning because that allows your inner clock to balance itself making it actually easier for your system to create and deploy the right hormones when you actually have to go to bed. So, there are certain factors that would be good if a player just gets to stick [them] on his spine. I always ask players, like, “do you brush your teeth in the evening?” They’re like, “that’s a strange question.” And then I ask them, “but do you, do it?” and usually they always say “yes”. Which is lucky for me and then I ask them, “do you think a lot about why you’re brushing your teeth and how you’re doing it? Or do you just do it?” And they all reply back more or less that they just do it. When it comes to sleep hygiene… sleep hygiene is not just what you do before you go to bed. But it’s things that you learn yourself to do throughout the day which ultimately will sit on your spine. So, you just do it as a pattern… as a habit, which ultimately leads to good sleep. Because the thing is, also, if you give sleep and sleep hygiene too much attention, it can also have an opposite effect, right? They want to optimise everything around how they go to bed so it becomes a stress factor which makes it more difficult to fall asleep which can also lead to awakenings during the night. So, it needs to be balanced. Elle Trezise: What would you say are, sort of, the top sleep hygiene techniques that you find really effective? Especially in elite footballers. Anna West: I think I’m always against creating this standardised list of five bullet points about what would help you fall asleep, and I always

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say to people, you know, Google. Because Google will tell you at least the five mostly used hits around the world when it comes to sleep. By my experience, one of the things that a lot of footballers find difficult is to shut down their brain, right? They have a racing mind just before they have to go to bed. You can use various techniques to lower the activity of your mind before going to bed. We know for a fact that just by writing things down on a piece of paper, research has shown that you can reduce sleep latency (meaning how long it takes for you to fall asleep) with around 50%. What I like to do is not just having people do a brain brainstorm, but actually write down what’s on their mind, why it’s bothering them, what they plan to do about it and when they plan to do something about it because then it becomes active, and you clean your brain and you put it away just before you go to bed. People would expect that it works the first time you do it, and it doesn’t. But cleaning your brain, making sure that you have downtime before you go to bed is massively important. Because a lot of them are just running on a very, very high energy level. All the time. Being exposed to a lot of things all the time. But that arousal level benefits from being taken down not just before you go to bed, but actually also during the day a couple of times where you actually allow your pulse level and your blood pressure to kind of drop down. So, in combination, making sure that you have sequences during the day where you’re relaxed and also before you go to bed. Another pointer would be, making sure that the room is cold and aired and it sounds like a no brainer. Now we’re recording this on a video and can see you nodding because it’s a no brainer for all of us. But a lot of people, they forget to do it. And one thing that works quite well with athletes as well is that they take a warm shower before they go to bed because it forces the cold temperature to drop down because you force the body to start sweating. Quite a lot of players will do the opposite. They will take a cold shower because they’re warm which actually has the opposite effect because it arouses them. It puts the level up, their pulse level up. When we have to go to sleep the pulse needs to drop down. So, a warm shower before going to bed is a massive influence as well. Then, again, making sure that the room temperature is low because they sweat a lot during the night. That’s two main factors.

FMPA podcast Making sure hydration is balanced is a major factor as well, and making sure that if you are sound sensitive, if you are light sensitive, that you do something about it. Not just recognise the fact that you find it annoying that you can hear noises and that it wakes you up. But actively then do something about it and it’s super simple quite often to make sure that there’s no light coming into your room and that you’re not disturbed by noise. Because all of that has nothing to do with you having a sleeping disorder. It’s external factors, but it can actually lead to quite poor sleep quality. Then, minimising your performance ability. Elle Trezise: Yeah. Thank you for outlining those. So, just in this world of, you know, smart tech, a lot of us that are into sports have sports trackers, fitness trackers - a lot of them measure sleep. Are you an advocate, personally, of sleep trackers? And if so, are there any that you recommend or personally use?

football medicine & performance own baseline and you will have the same deficit of the data continuously. Do I use trackers? Yes, I do. Do I implement them with a cautious mind in relation to what player I’m working with? Yes, I definitely do. I recently did a project. I can’t tell you who I did it with, but let’s just call them a very big team and they were all offered to use sleep tracking technology. Kind of state-of-the-art version of what’s on the market. I was onboarded into the project after a couple of months and when I came into that project, 70% of the players were actually not using the technology. It was just lying in a drawer somewhere because they didn’t like to see the data. One thing was just seeing the data, but then I think that the deal breaker in that case, and in many cases, would be you see the data, but you don’t know how to change it. So, if you don’t have the tools in hand to actually change the negative data that you see, either they take it off or it alludes to even further sleeping problems.

Anna West: I think I’ve tested not everything on the market, but I am definitely a fan of being able to track objective data. I am at the same time an advocate of using common sense. In the sense of understanding that the adaptation [of different players] to technology is very different and also have a mythology which is based on technology being a support but not a solution.

Elle Trezise: That’s great. My last question is, you know, obviously you’ve worked with some very high-profile clubs, but let’s say a club really wants to help their footballers with their sleep, but they lack the money and the resources to get a specialist such as yourself on board. What are some of the basic things they can put in place?

So, for some players, it in all honesty can lead to worse sleep once they start to track themselves because sleep becomes a stress factor. Let’s say you’re very detail orientated, you want to optimise everything and all of a sudden you just see negative sleep data. Then you having access to that type of data is actually imposing more stress on you than it’s actually helping you to optimise the sleeping side.

Anna West: I think step number one would be to make sleep a part of the performance enhancement strategy. Like, acknowledge that sleep is a deal breaker. It needs to be a bit of the

So, I don’t think that there’s a standardised one-size-fits-all answer to that. There are a lot of good technology out there. There’s also a lot of crap technology out there. I think it’s super important that you, in that aspect, use your common sense as well. In terms of analysing yourself with that common sense, say you wake up and you felt like you were sleeping great, and you try that for a couple of days and the tracker is showing you very poor data, then I would stick to my gut feeling rather than the data. If you look at the evidence and the testing on quite a lot of the trackers, they’re severely either underestimating or overestimating the sleep output. I always say that if you continue to use the same tracker, at least you’ll be your

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mindset of the club and people. Both staff and players need to be educated to get the ammunition to understand. “Why should we invest in sleep? What’s the benefits?” Maybe also in bullet points some of the basic things that you can do, in order. But education is key. And then secondly, I would use some power as well to understand both environmental but also individual sleep challenges and there are some pretty good questionnaires available that you can use. They will not give you the full detail, but it might allow you to have some insights to your environmental challenges. And understand as well that if you want to create some changes, do not try to apply this one-size-fits-all model because players adapt very, very differently to sleep hygiene mythology, as an example. So, make sure that you understand your team and make sure that you have an idea about where the sleep compromisation is coming from. Is it scheduling? Is it pressure? Is it…? Rather than just concluding that we have sleeping challenges. Elle Trezise: Anna, I’m going to draw that to a close. That was really fascinating. I picked up lots of insights. I’m sure the listeners have too. Thank you so much for joining us today. Listeners, if you enjoyed today, please subscribe to the FMPA podcast on Spotify or SoundCloud. Alternatively, you can check out the podcast section of the FMPA website. Thank you for listening to the Football Medicine and Performance Podcast. Have a great day.

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football medicine & performance - Spring 2022 - Issue 38

Articles inside

Fuelling for the Work Required in Professional Football: A Theoretical Model for Carbohydrate Periodisation

Imaging in Football Medicine

COVID-19 Recovery in Athletes The UK World Class Olympic and Paralympic Experience

A Flock of Birds and the Complex Systems: Unfolding the Characteristics of Complex Systems in Sports Injury Rehabilitation

Personalising Female Footballer Hormone Health

Interns, Placements & Morals An Ethical Tale