Summer - Issue 39

The official magazine of the Football Medicine & Performance Association

football medicine & performance

Issue 39 Summer 2022

In this issue Dr Carl Todd: 200th England Game as an Osteopath Painkiller

Misuse in Football, Part of the Job? Treatment of Meniscal Lesions in Professional Footballers EURO 2020: Hosting a Major Football Tournament During a Global Pandemic – The UK Perspective

Legal • Education • Recruitment • Wellbeing

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CEO MESSAGE The appointment of education team members in support of our magazine is a significant step forward in the development of our highly respected publication.

As we approach our 40th edition later this year we are now set to enhance and expand our reach for articles and will continue to bring you the latest up to date information and opinion in our trademark format. The driving force behind the magazines growth has come solely from the Editorial team, Sean, Andrew and Fadi who have worked tirelessly in putting together each edition while still in full time employment themselves.

As an association we rely on members support and I believe that as a community there is so much further we can go. The importance of member involvement and contribution to the FMPA remains key to our success and of course the more we advance our cause the more we can offer in terms of support. Certainly in the near future we will be looking for members to make decisions on a range of topics and then to implement and action those decisions moving forwards.

Very occasionally there are milestones within our industry which make us pause and reflect for a second. The news that our erstwhile colleague Derek Wright is finally set to retire from his role at Newcastle United after 38 years is worthy of that reflection since within our sector we are not likely to see one of our members reach anywhere near this milestone again.

Derek is one of the old school who has been there and seen it all. From being the only medic at the Club in the mid-eighties to witnessing a medicine and performance department of over 30 staff he has navigated the changes throughout that time and is one of the most highly respected people in the game amongst colleagues, managers, players and fans alike.

On behalf of all our members I would like to take this opportunity to wish him well in his new ventures.

Eamonn S almon

Chief Executive Officer Football Medicine & Performance Association

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FROM THE EDITORS The 39th Edition of the Football Medicine and Performance editorial is among us as we embark on another footballing season.

Reflecting on this time last year and Euro 2020, Stephen Boyce and Mike Patterson discuss lessons and the challenges of hosting a major football tournament with the added complication of doing so during the global pandemic.

Another reflection shared in this edition is one from Carl Todd. Carl is a renowned name in the game with years of experience as an Osteopath at club and international level. Here, he shares his insights into his journey leading to 200 international games as an Osteopath. Carl was also our July guest on the Football Medicine and Performance podcast so head over to our podcast page to listen to Carl talk about his journey.

With training loads increasing from the pre-season phase into the season, Frankie Hunter and Co share a comparison of the weekly training loads of English Premier League academy players. This spike in training load can increase injury risk and therefore the increased input of medical staff and medical management. In this edition, Daniel Read discusses a key article on Painkiller misuse in football.

This edition also marks the start of a partnership with the FA Medical Society, with members of our education team transcribing the quality FA Medical Society CPD events for our readership. Our first transcribed FA Medical Society event is on the interesting topic of Osteochondral Lesions of the Knee, an event held during the latter part of last season.

The “Three P’s of Productive Performance” workshops took place over 3 virtual workshops held over the second week of June and was a huge success. A huge congratulations to Kevin Paxton and team for their hard work in organising insightful workshops. These can all be accessed online through the members area of the website.

Lastly, a big congratulations to the new members of the education team. The FMPA were overwhelmed with applicants, a real credit to the members of the community. Keep your eyes peeled on future editions as we share with you profiles of our new members.

We hope you enjoy this edition and good luck for the upcoming season.

Sean Carmody Dr Sean Carmody Editor, FMPA Magazine

Fadi Hassan Dr Fadi Hassan Editor, FMPA Magazine

Andrew Shafik Dr. Andrew Shafik Editor, FMPA Magazine

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CONTENTS FEATURES

10 Dr Carl Todd: 200th England Game as an Osteopath 12 Painkiller Misuse in Football, Part of the Job? Daniel Read, Aaron C.T. Smith, James L. Skinner 15 FMPA Business Partners 2022/23 18 The Sleeping Giant - The Extraordinary Importance of Sleep for Athletes Craig Lewis

28 ‘Bridging the Gap’ – The Role of Individualisation in Managing the Physical Transition Between ‘Part-time’ and ‘Full-time’ Academy Football Frances Hunter, Jonathan Taylor 32 An Introduction to Key Issues in Footballer Welfare Kirsty Burrows 40 EURO 2020: Hosting a Major Football Tournament During a Global Pandemic – The UK Perspective Stephen Boyce, Mike Patterson

20 Treatment of Meniscal Lesions in Professional Footballers Kyle Borque, Mary Jones, Mitzi Laughlin, Moises Cohen, Darren Johnson, Andy Williams 24 Osteochondral Lesions of the Knee Football Association Medical Society

ABOUT

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COVER IMAGE

Chief Executive Officer Eamonn Salmon eamonn.salmon@fmpa.co.uk

Photography Alamy Images, FMPA, Unsplash

Football Medicine & Performance Association.

All rights reserved.

Contributors Daniel Read, Aaron C.T. Smith, James L. Skinner, Kyle Borque, Mary Jones, Mitzi Laughlin, Moises Cohen, Darren Johnson, Andy Williams, Football Association Medical Society, Carl Todd, Frances Hunter, Jonathan Taylor, Stephen Boyce, Mike Patterson, Daniela Mifsud, Craig Lewis.

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

Marketing/Advertising Commercial Manager Angela Walton angela.walton@fmpa.co.uk Design Oporto Sports www.oportosports.com

Ki-Jana Hoever of Wolverhampton Wanderers is taken off the pitch following an injury during the Premier League match.

Alamy Stock Photo

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feature

DR CARL TODD: 200TH ENGLAND GAME AS AN OSTEOPATH FEATURE / Dr Carl Todd has been providing osteopathic care at The Football Association for the England Men’s senior team since 2005. On June 14th this year he marked his 200th game for the senior team as they played Hungary at the Molineux Stadium as part of the qualification process for the UEFA Nations League.

It all started back in 2005 when Carl was recommended to the men’s senior team head of physiotherapy Gary Lewin. Following a trip to The Lowrey Hotel in Manchester to review some players, Carl was introduced to Sven Goran Erikson and his coaching team. Dr Todd had been recommended from a private patient that had contacts in football and the moment he was introduced to Gary, the rest is history! Since then, fast forward over 17 years and 7 managers later, Carl has reached a point in his professional career that even he admits “he has to pinch himself” because he never expected this role “to last that long”. “I’ve stood the test of time, but I’ve been extremely fortunate to have worked alongside many great sports

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medicine clinicians and physiotherapists and I’ve learnt and I am still learning from them all” Carl added.

During this time, he has attended numerous tournaments including FIFA World Cups in Germany (2006), South Africa (2010), Brazil (2014), Russia (2018), and later this year he will be attending his fifth World cup tournament in Qatar. Other competitions include the UEFA European championships, Poland and Ukraine (2012), France (2016) and Euro 2020. Carl admits that success is tough at international level.

“Whilst part of the England’s men senior team we reached the World Cup quarter final in 2006, the World cup semi-final in 2018 and the final in Euro 2020, hopefully, this year, we can go one better” Carl enthusiastically added.

Dr Todd explained how amazing his journey thus far has been, “I’ve been extremely privileged to work in elite sport at the highest level for a long time. I have learnt so much from the staff, my fellow colleagues and players throughout this time and it certainly has helped to shape me as an individual and help inform my clinical reasoning strategies”.

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Carl Todd was the first osteopath to be integrated into a multidisciplinary team at The FA and throughout this time, he has worked alongside many great clinicians, including the likes of Gary Lewin, Steve Kemp and Dr Ian Beasley to name but a few. Carl’s own skill set has been developed throughout this time frame with him being the first osteopath (non-physician or physiotherapist) to successfully pass and then successfully recertify on the Advanced Trauma and Medical Emergency course.

Education has played a huge part in Carl’s life, over the years, he has developed his own style of osteopathy that integrates functional, clinical and bio-psychosocial aspects to address an athlete’s complaint. This is what he preaches, and what he teaches, when lecturing in workshops and courses. Moreover, this has enabled him to build a network in assisting other premiership clubs to find suitable osteopaths to complement their own multidisciplinary teams. His academic achievements include an honours degree in osteopathy, a master’s degree in sports medicine, a PhD in clinical orthopaedics and a

football medicine & performance

certificate in strength and conditioning. Carl had published over twenty research articles in peer reviewed journals and in November this year his first book, that combines his clinical experience and evidence-based knowledge entitled “Managing the Spinopelvic-hip complex: an integrated approach” will be published by Handspring publishers.

However, it hasn’t all been about the England team and The FA for Carl. He has also provided osteopathic care at club level from 2009 for Chelsea Football Club where he has been fortunate enough to work in a multidisciplinary team supporting a team of players that have won every domestic, European and international trophy that a football team can win. Other sports that Carl has worked in include basketball where he worked with the male and female GB teams at the London 2012 Olympics. In 2019, he also worked in Track and Field, more specifically in athletics with star athlete Dina Asher-Smith, providing osteopathic care for her in the Diamond League, British Championships and Tokyo 2020 Olympics, and for the upcoming British, European, Commonwealth and World Championships in 2022.

Private practice sees Carl manage four different clinics across the south west of England and in London alongside his wife Mel. More recently, Carl has started to provide a consultancy service for medical teams and athletes across many sports, where he specialises in complex case management and offering second opinions for long-term sports-related and MSK problems in athletes. For further details please see www.drcarltodd.com or www.carltoddclinics.com

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PAINKILLER MISUSE IN FOOTBALL, PART OF THE JOB? FEATURE / DANIEL READ, AARON C.T. SMITH & JAMES L. SKINNER Introduction If boxing is the ‘hurt game’ then professional football has surely become the ‘pain game’.

Individualism and a competitiveness are deeply embedded within professional football and while these values make for dramatic sport experiences, it also means that players are treated as commodities that can be retired and discarded once their physical capabilities are exhausted. In order to remain employable for as long as possible, professional footballers endure significant physical trauma that leaves them bruised, battered, and vulnerable to varying levels of post-game, and ultimately, post-career, stress.

Of course, some commentators might argue that at least a small percentage of professional footballers are exceptionally well rewarded for their pain and that the former description of big-time sport is alarmist and exaggerated.

However, our research exposes the ways in which painkilling drugs can be seen as tools that sport managers, coaches, scientists, and players use to maximise game time and longevity.

So, while the presumption that players should be able to manage their bodies in ways that are consistent with their own beliefs about

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the practice and performance of sport, we have confronted the disconcerting possibility that players need protection from imposed drug misadventures and misjudgements.

Painkiller Misuse in Football In recent years, numerous high-profile retired footballers have admitted to painkiller misuse during their careers that led to long-term harm (Read et al., 2022). The therapeutic use of analgesic substances and injections is common practice in football to enable players to compete through minor injuries, however, sport physicians have raised concerns about painkiller (mis)use without medical need and/or supervision in football (Correctiv, 2020; Tscholl & Dvorak, 2012). Our research aimed to understand the motivations for painkiller misuse from a relational perspective by considering the interaction between player experiences and their working environments. In exposing the pressures footballers are under to use painkilling drugs, we have been able to identify a set of risk factors sports medicine practitioners can employ to locate and assist players vulnerable to misuse in order to reduce harm and prevent long-term damage.

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Sport clubs, no matter the performance level, like to see their athletes available for selection as soon as possible after injury, meaning overthe-counter painkillers are widely used to relieve discomfort and enable increased range of movement. Additionally, painkilling drugs may offer temporary performance enhancement although effects vary by substance (Holgado et al., 2018). As a result, perhaps unsurprisingly, painkiller misuse is common across endurance, collision, and combat sports (Harle et al., 2018) with these athletes reporting higher levels of painkiller use relative to the general population (Alaranta et al., 2006).

To complicate matters, given the clandestine nature of painkiller misuse, limited data are available specifying the extent of the problem in football. Reports from Germany have highlighted that both professional (Trinks et al., 2021) and amateur footballers (Correctiv, 2020) are engaging in prophylactic painkiller use without medical need. Likewise, medication reports provided by team doctors covering the 72 hours before kick-off at World Cup matches indicated that painkiller use is common at the highest level of the game (Oester et al., 2019).

Figure 1 shows that of the 736 players from 32

football medicine & performance countries present at the 2018 World Cup, approximately 2 in 5 used a non-steroidal anti-inflammatory drug (NSAID) at some point and approximately 1 in 5 used an analgesic. Anecdotal stories of painkiller misuse are also plentiful with players reporting habitual painkiller consumption contravening medical guidance as part of a psychological routine or to deal with long-term pain from injuries or surgery (Read et al., 2022). Although the lack of data makes it hard to ascertain the true scale of the issue, recent research including ours suggest that misuse is more common than publicly acknowledged.

The misuse of painkillers is worsened by the fact that most analgesic substances are not banned by the World Anti-Doping Agency and are available from team medical staff. Additionally, paracetamol and NSAIDs are readily accessible from pharmacies without a prescription in most countries. The combination of legality and availability has led to a perception among athletes that painkilling drugs are safe in comparison to prohibited substances (Fincoeur et al., 2020). In reality, extended misuse of painkillers can lead to gastrointestinal damage, renal and hepatic failure, cardiovascular problems, addiction, and long-term musculoskeletal conditions (Warden, 2009). We do note that legitimate therapeutic painkiller use under proper medical supervision to enable players to compete through minor injuries also presents risks, such as injury exacerbation, but medical practitioners are more readily able to monitor players and prevent harm.

Research in other sports has pointed to a variety of precursors leading to painkiller misuse, including performance enhancement, loyalty to teammates, and avoiding being labelled as ‘weak’ or ‘soft’.

Notably there is a dearth of studies focusing on pain, injury, and working conditions as drivers of painkiller use and misuse in football (Roderick, 2006; Roderick et al., 2000; Roderick & Schumacker, 2017). Our research therefore began by assuming that identifying the pressures professional footballers face contributing to the decision to use painkillers, would help reveal how they might be best safeguarded from harm.

Our approach was to look at the problem from the position that football players have a finite period through a professional career in which to convert their footballing and bodily ability into economic rewards. As a result we found that professional players are forced to make a trade-off; their physical health in exchange for economic prosperity, or more specifically, physical capital for economic capital (Bourdieu, 1986).

Physical capital and player working conditions?

Our review of studies into the experiences of professional football players alongside the analyses of interviews with players who admitted to prophylactic misuse identified a working environment characterised by (1) risk of injury (2) employment vulnerability, (3) lack of alternate employment opportunities, and (4) reward for loyalty and toughness.

Each of these four elements aggregated to cultivate a workplace encouraging the systematic use of painkilling drugs.

First, the career of a professional footballer will inevitably be challenged by injury and a player can typically expect 2 injuries per season of varying severity (Ekstrand et al., 2011). Player welfare remains a hot topic in football medicine, and the increasing physical intensity of matches and congested playing schedules remain a point of contention as players are expected to compete in an ever-escalating number of games. With intensified playing schedules and workloads comes an inevitable increase in the risk of injury (Bengtsson et al., 2013). Against the backdrop of a limited window for commercial gain, injuries are a threat to a player’s relatively brief economic window of activity.

Second, most footballers face employment vulnerability and risk of replacement. For instance, in 2018, the longest average contract given to players across Europe’s big five leagues was 3.23 years, (FC Barcelona) whilst the shortest average contract length was 0.99 years (Amiens SC) (Poli et al., 2018). Relatively short-term employment guarantees are compounded by the sheer volume of competition for a limited number of work opportunities and the constant supply of new talent through academies and scouting. Again, prophylactic painkiller misuse mitigates against potential lost playing time and offers psychological boosts to showcase a player’s talent in pursuit of further employment at the end of a contract.

Third, in pursuit of a professional career, most footballers sacrifice other areas of personal development, such as the attainment of formal educational qualifications (Adams & Darby, 2020; Agergaard & Sørensen, 2009; McGillivray et al., 2005). Players find themselves in a position of dependence upon their footballing career given the uncertainty that often accompanies retirement due to a lack of perceived opportunities.

Therefore, players are dependent upon maximising the economic rewards available through their limited career spans.

Fourth, professional football culture rewards loyalty to teammates and toughness (Roderick, 2006; Roderick et al., 2000). Players who are frequently injured, unwilling to play through

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injury, or simply fatigued, are considered a liability (Cunningham, 2018). Such working conditions are conducive to painkiller misuse to meet powerful cultural expectations.

The working environment of professional football is highly conducive to painkiller misuse as most footballers outside the cadre of players able to retire on their career earnings are faced with a dwindling time window to convert footballing ability into economic reward. The short career span is exacerbated by injury, short-term contracts, employment dependency, and a masculine culture towards pain. Based on these working conditions, risk factors for misuse can be identified and used to assign risk scores.

1.

Players approaching the end of their contract.

2.

Players approaching the end of their career.

3.

Players with a high training and match workload.

4.

Players recovering from recent surgery using painkillers.

5.

Players with a history of severe injury.

6.

Players who have an image of being tough.

7.

Players with few vocational or educational qualifications.

8.

Fringe players with unstable positions in the team.

Harm Reduction and Closing remarks The problem of dealing with painkiller use is bound up in the culture and context of contemporary sport. Given sport’s hypercompetitive and hyper-commercial values, it is impossible to envisage a professional footballing world without painkilling drugs. At the same time, it is hard to deny the need for some form of regulation to protect sport and its various stakeholders from the organisational and human costs that arise from uncontrolled substance use. One option is a harm reduction policy that allows athletes to manage their usage in a safe and secure environment. While a harm reduction policy is controversial in sporting circles, it accepts that drugs will always be part of the sporting landscape and aims to minimise the harm associated with their use.

Given the stakes at risk for professional footballers, it seems sensible that a harm reduction attitude towards painkiller misuse is considered rather than a strict abstinence approach seen in other substance use policies. The nature of a professional sports career means that a footballer’s physical readiness will often be in a grey area influenced by fatigue, previous injury, and psychological attitude and practitioners

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feature

face a difficult decision in determining whether to prescribe analgesics. Therefore, open honest dialogue with players about risk and rewards and safe usage should be privileged.

It is beyond the remit of sports physicians to resolve the work pressures players are subject to, however, practitioners are well positioned to reduce the potential damage footballers may inflict upon themselves. Practitioners are therefore advised to: 1.

Identify individuals who may be susceptible to painkiller misuse.

2.

Research attitudes and behaviours towards unsupervised prophylactic painkiller use within the squad.

3.

Work holistically with performance staff to reduce workload where possible.

4.

Educate players about safer practices, addiction, and alternative substances and methods to lessen risks.

5.

Highlight post-career player development initiatives and engage with exit health examinations.

We conclude that prophylactic painkiller misuse is better understood as a result of working context and experience rather than of individual deviance.

Professional football players who take painkilling drugs are not exceptions, cheaters, or addicts, but rather are caught between the unwelcome options of playing and making a living using painkilling drugs, or of being discarded and jobless but without the deleterious health effects of painkilling drugs.

Unfortunately, as we discovered, the two are not always mutually exclusive because the former group are ultimately forced to retire and many do so with the damage already done, and with a lifetime of drug use ahead of them to live without pain.

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Adams, R., & Darby, P. (2020). Precarious pursuits, broken ‘dreams’ and immobility among Northern Irish soccer migrants. Sport in Society, 23(5), 920–937.

Agergaard, S., & Sørensen, J. K. (2009). The dream of social mobility: Ethnic minority players in Danish football clubs. Soccer & Society, 10(6), 766–780.

Alaranta, A., Alaranta, H., Heliövaara, M., Airaksinen, M., & Helenius, I. (2006). Ample use of physician-prescribed medications in Finnish elite athletes. International Journal of Sports Medicine, 27(11), 919–925.

Bengtsson, H., Ekstrand, J., & Hägglund, M. (2013).

Muscle injury rates in professional football increase with fixture congestion: An 11-year follow-up of the UEFA Champions League injury study. British Journal of Sports Medicine, 47(12), 743–747.

Bourdieu, P. (1986). The forms of capital. Cultural Theory: An Anthology, 1, 81–93.

Correctiv. (2020). A Kick on Pills; Painkillers in Football. https://correctiv.org/en/topstories/2020/06/08/kickonpills/ Cunningham, S. (2018). Painkiller addiction, broken legs and depression: The shocking toll of playing through pain revealed. The Independent.

Ekstrand, J., Hägglund, M., & Waldén, M. (2011).

Injury incidence and injury patterns in professional football: The UEFA injury study. British Journal of Sports Medicine, 45(7), 553–558.

Fincoeur, B., Henning, A., & Ohl, F. (2020). Fifty shades of grey? On the concept of grey zones in elite cycling. Performance Enhancement & Health, 8(2–3), 100179.

Harle, C. A., Danielson, E. C., Derman, W., Stuart, M., Dvorak, J., Smith, L., & Hainline, B. (2018).

Analgesic management of pain in elite athletes: A systematic review. Clinical Journal of Sport Medicine, 28(5), 417–426.

Holgado, D., Hopker, J., Sanabria, D., & Zabala, M. (2018). Analgesics and sport performance: Beyond the pain-modulating effects. PM&R, 10(1), 72–82.

McGillivray, D., Fearn, R., & McIntosh, A. (2005).

Caught up in and by the beautiful game: A case study of Scottish professional footballers. Journal of Sport and Social Issues, 29(1), 102–123.

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Oester, C., Weber, A., & Vaso, M. (2019).

Retrospective study of the use of medication and supplements during the 2018 FIFA World Cup Russia. BMJ Open Sport & Exercise Medicine, 5(1), e000609.

Poli, R., Besson, R., & Ravenel, L. (2018).

Contract policy: Spanish giants head the table.

CIES Football Observatory. https://footballobservatory.com/IMG/sites/b5wp/2017/222/en/ Read, D., Smith, A. C., & Skinner, J. (2022).

Theorising painkiller (mis) use in football using Bourdieu’s practice theory and physical capital.

International Review for the Sociology of Sport, 10126902221082484.

Roderick, M. (2006). Adding insult to injury: Workplace injury in English professional football.

Sociology of Health & Illness, 28(1), 76–97.

Roderick, M., & Schumacker, J. (2017). ‘The whole week comes down to the team sheet’: A footballer’s view of insecure work. Work, Employment and Society, 31(1), 166–174.

Roderick, M., Waddington, I., & Parker, G. (2000).

Playing hurt: Managing injuries in English professional football. International Review for the Sociology of Sport, 35(2), 165–180.

Trinks, S., Scheiff, A., & Gotzmann, A. (2021).

Declaration of Analgesics on Doping Control Forms in German Football Leagues during Five Seasons.

German Journal of Sports Medicine/Deutsche Zeitschrift Fur Sportmedizin, 72(2).

Tscholl, P. M., & Dvorak, J. (2012). Abuse of medication during international football competition in 2010–lesson not learned. British Journal of Sports Medicine, 46(16), 1140–1141.

Vaso, M., Weber, A., Tscholl, P. M., Junge, A., & Dvorak, J. (2015). Use and abuse of medication during 2014 FIFA World Cup Brazil: a retrospective survey. BMJ open, 5(9), e007608.

Warden, S. J. (2009). Prophylactic misuse and recommended use of non-steroidal antiinflammatory drugs by athletes. In British journal of sports medicine (Vol. 43, Issue 8, pp. 548–549).

British Association of Sport and Exercise Medicine.

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THE SLEEPING GIANT – THE EXTRAORDINARY IMPORTANCE OF SLEEP FOR ATHLETES FEATURE / CRAIG LEWIS

Within the world of sport, the importance of sleep as a key tool to aid recovery and regeneration is starting to gain traction within mainstream sports science. Previously, sports science practitioners, in the search to gain the merest of advantages, had tended to look at more ‘sexier’ options in order to assist the athlete to gain the slightest edge from a regeneration point of view. Ice and contrast baths, compression socks, cryo-chambers, cryo-saunas and a host of other technological advances have undoubtedly been shown to improve the level of athlete recovery through either anecdotal or research based evidence but without question, the importance of sleep should never be compromised nor overlooked in the ultimate search to assist in the body’s ability to recover.

THE IN’S AND OUT’S OF SLEEP A BASIC UNDERSTANDING OF SLEEP Basic sleep patterns are determined by the body’s circadian rhythms which are physical, mental and behavioural changes that follow a roughly 24-hour cycle, responding primarily to light and darkness in an organism’s environment.

Within that cycle, the onset of sleep is largely determined by the hormonal secretion of a substance called melatonin whose primary function is the regulation of the body’s circadian rhythm. In general, the body begins to secrete the hormone at the onset of darkness and reduces the levels of secretion at the onset of light. Melatonin generally impacts on the body by reducing core body temperature, synchronising circadian rhythms and increasing drowsiness.

In general, most adult individuals require approximately 7 to 9 hours of sleep a day, while teenagers and infants generally require additional sleep in order to function optimally during the course of their waking hours.

Generally, the younger the person, the more time they require from a sleeping perspective.

Nick Littlehales1, a contemporary expert on the effect of sleep deprivation on athletic performance and the management of sleep to enhance athletic

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recovery, has stated that rather than thinking in terms of large blocks of time at night, one should rather think of sleep patterns in respect of periods of 90 minute cycles and that within a week, an athlete should accumulate a minimum of around 35 cycles. Should the athlete not accumulate approximately 7.5- 8 hours a night or around 5 cycles, they would be able to top that up with catch-up periods during specific times of the day.

THE SLEEP EFFECT - UNDERSTANDING THE IMPACT OF SLEEP ON THE BODY The impact of sleep has enormous implications on the ability of the body to function optimally and in accordance with Van Schie2, deep sleep cycle is important for the production of HGH which is vital for muscle and tissue recovery, injury prevention and inflammation reduction while the REM cycle is important for memory consolidation.

A reduction in sleep whether over the short term or for an extended period of time has been shown to have multiple negative effects on the body as it pertains to athletic performance.

Sleep deprivation over an extended period of time has shown to have the following effects on mental and physical bodily functions including: • • • • •

Learning, memory and cognitive function; Pain perception; Immunity from disease; Inflammation; Carbohydrate metabolism and protein synthesis; • Appetite and food intake or choices.

Halson3 in her article pertaining to sleep deprivation and the effects on athletic performance found that sleeping less than 6 hours a day for a period of 4 days had the following effect on performance: • Impairs cognitive function and mood; • Disturbs glucose metabolism; • Had negative consequences for appetite regulation and • Impacts negatively on immune function.

While Milewski et al4, in looking specifically at the effect of sleep deprivation on injury management came to the alarming conclusion that athletes who slept less than 8 hours per night (approximately around 6 hours per night) over a period of two years were 1.7 times more likely to have had an injury in that period than an athlete who had slept for around 8-9 hours.

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SLEEP DEPRIVATION ON ATHLETIC PERFORMANCE In respect of physical performance, Le Meur and Hausswirth5, showed that even moderate sleep deprivation has been shown to have a deleterious effect on performance, this included both explosive strength and dynamic (isokinetic) strength. Littlehales6, showed a link between sleep deprivation and a significant reduction in isokinetic performance as well as a significant reduction in vertical jump performance (a measure of lower limb explosive strength). He also showed that sleep deprivation led to the inability to maintain sprint time, reduced peak voluntary force, reduced voluntary activation, increased perceptual strain and reduced maximal strength.

According to Le Meur et al4, a number of theories have been advanced as to the source of this drop in performance (in conjunction with an increase in sleep deprivation) including: alteration of the cardiorespiratory system, reduced endurance of the respiratory muscles, later sweating, increased metabolic acidosis and finally, a reduced efficacy of enzymes involved in aerobic metabolism.

SLEEP DEPRIVATION AND THE PHYSIOLOGICAL EFFECT ON THE BODY Despite the obvious effect of increased sleep deprivation on athletic performance, an increased level of sleep deprivation also plays a large role on the impact of the body’s ability to recover post-exercise.

In this regard, Skein et al7, assessed the effect of intermittent sprint performance on muscle glycogen stores after 30 hours of sleep deprivation. Their findings concluded that the combination of sleep deprivation and reduced muscle glycogen stores as a result of consecutive days of activity, reduced overall performance during intermittent sprint exercise for athletes.

This study thereby showed the importance of a correct nutritional strategy, in combination with good sleep practice, has the ability to ensure better recovery for athletes involved in activities which are on consecutive days. Obviously, for a professional athlete who is likely to train on multiple consecutive days, the impact on overall performance would be greatly affected through an incorrect combination of poor sleep hygiene and an inadequate nutritional programme.

From a muscle recovery perspective, Dattilo et al8, demonstrated the importance of sleep in response

football medicine & performance to changes in the hormonal system which in turn directly affected a loss of muscle mass. This occurs through a shift in the production of cortisol (increase) and a reduction in testosterone and Insulin-like Growth Factor 1. The study hypothesized that sleep deprivation decreased the activity of protein synthesis pathways while simultaneously increasing the activity of degradation pathways.

The direct consequence of this would lead to a loss of muscle mass and resultantly hinder muscle recovery after damage. Resultantly, an athlete with an increased sleep debt would likely be more challenged in respect of increasing their muscle mass but more importantly for an athlete to recover correctly and to adapt sufficiently to daily training load, sleep deprivation would negatively impact on adaptation and the ability to recover from training specifically designed to induce muscle damage on a micro level. In this regard, the athlete returning to play from injury, would also be greatly impacted on in respect of a decrease in the ability to recover at the same rate were they to have repeated periods of sleep deprivation.

From a sleep deprivation and immune response perspective Besedovsky et al9, found that sleep and the circadian system exerted a strong regulatory influence on immune function. Besedovsky et al also noted that current research has shown strong evidence that sleep does indeed positively enhance immune defense. Simultaneously these researchers found that prolonged sleep deprivation and the accompanying stress response invoked a persistent unspecific production of pro-inflammatory cytokines which ultimately induce low grade inflammation as well as immunodeficiency which will obviously impact on the body’s ability to maintain healthy levels.

Obviously, for an athlete, the increased exposure to consistent sleep deprivation would lead to a lowering of the immune system which would in turn affect the body’s response to fighting disease. Consequently, in periods of increased stress whereby the athlete heightens the level of training volume and intensity, possibly in response to their upcoming competition phase, this could, in combination with increased periods of reduced sleep (due to possible psychological stress, increased daily sessions etc.), further elevate the risk of a poor immune response. This could ultimately result in a vicious cycle of continual bouts of immune deficiency in conjunction with sudden increases in training volume and intensity (due to lost training time) which could negatively impact on the potential for injury and illness.

INTRODUCING CORRECT SLEEP HYGIENE INTO THE TRAINING PROGRAMME - PRACTICAL APPLICATION OF GOOD SLEEP HYGIENE Therefore, one is able to deduce from all of the above information, the absolute necessity of introducing a corrective sleep hygiene programme for any given athlete. Given the fact that even moderately reduced sleeping hours and disturbed sleep patterns can negatively impact on both the body’s ability to perform as well as adequately

recover, I believe it essential to educate athlete’s on the importance of introducing (if not already existing) and consistently maintaining a programme of good sleep habits.

In this regard, Halson3 gave some very practical but simple advice to assist athletes to attempt to undertake the following patterns in order to improve the quality of their sleep patterns: • The bedroom should be cool, dark and quiet. Eye masks and ear plugs can be useful, especially during travel • Create a good sleep routine by going to bed at the same time and waking up at the same time • Avoid watching television in bed, using the computer, phones or tablets in bed (approximately 2 hours before bed) and avoid watching the clock • Avoid caffeine approximately 4 to 5 hours prior to sleep (this may vary between individuals) • Do not go to bed after consuming too much fluid as it may result in waking up to use the bathroom • Napping can be useful, however generally naps should be kept to less than 1 hour and not too close to bedtime as it may interfere with sleep So, from a practical perspective in terms of an athlete’s daily routine, if for example they are training once a day in the morning as is often the case for team based sports, their routine may look something like this: 22:30- 06:30 Sleep- always attempt to be regular in respect of time to sleep and awaken 06:30- 07:00 Light breakfast 07:30 Approximate time when melatonin secretion stops 09:30- 11:30 Training session 13:00- 13:30 Lunch 14:00-15:00 Rest- approximately around 30 minutes but certainly no more than an hour 15:30- 16:30 Regeneration sessionstretch, massage or other forms of recovery 18:30- 19:00 Dinner 20:00- 20:30 Stop usage of all electronic devices which may affect sleep pattern 21:00 Approximate onset of melatonin secretion 22:00- 22:30 Light reading (nonelectronic device) or other form of relaxation 22:30 Bedtime Of course, this routine would alter depending on the athlete’s schedule in respect of training times or competition times but always keep in mind the importance of sleep as a fundamental tool for performance regeneration.

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NUTRITION AND SLEEP From a nutritional perspective, the key ingredient to improving the onset of relaxation and sleepiness is an essential amino acid by the name of tryptophan. Essentially, tryptophan is a key ingredient in the body’s production of both serotonin and in turn melatonin. And as an essential amino acid, the body requires it from dietary sources. Fortunately, tryptophan is found in most protein based foods but is particularly plentiful in fish, eggs, poultry, red meat, dairy, oats, dates, sesame, chickpeas, almonds sunflower seeds, pumpkin seeds, buckwheat, spirulina, bananas, cherries and peanuts. Often, when the abovementioned tryptophan-rich based ingredients are combined with carbohydrates, the produced effect does lead to enhanced feelings of drowsiness.

Countering that, the following foods will generally reduce or disrupt sleep cycles: • • • • • •

Foods high in fat content; Caffeine rich foods and drinks; Energy drinks; Sugary based drinks; Spicy foods Alcohol

IN CONCLUSION With so much conclusive evidence to suggest the overriding benefit of having a “good night’s sleep”, it is essential that in order to improve both athletic performance during competition and to adequately recover from daily activity, that correct sleep patterns should be at the forefront in the regeneration arsenal of any athlete, coach or sports scientist.

Of course, in conjunction with corrective sleep hygiene, nutrition is both a massively important ingredient in both the promotion of sleep as well as a co-initiate in the athlete’s overall ability to both overcome the impact of physical work on the body as well as the ability to successfully navigate multiple days of intense hours of hard training.

1. Littlehales, N. (2015). Sleeping on the Job: The importance of rest for peak performance. Gallan, D. ConqaSport.

2. Van Schie, J. (2015). Sleeping on the Job: The importance of rest for peak performance. Gallan, D. ConqaSport.

3. Halson, S. L. (2014). Sleep and the Elite Athlete. GSSI. 4. Milewski, M. D., Skaggs, D. L., Bishop, G. A., Pace, J. L., Ibrahim, D. A., Wren, T. A., Barzdukas, A. (2014). Chronic lack of sleep is associated with increased sports injuries in adolescent athletes. J Pediatr Orthop. 34(2): 129-33.

5. Le Meur, Y., Hausswirth, C. (2015). Sleep and Sporting Performance. Asp Sp Med J. Vol 4. 6 6. Littlehales, N. (2015). Sleep Recovery in Sport- KSRI’s Key Sleep Recovery Indicators. Sportsleepcoach. Nov. 2015 7. Skein, M., Duffield, R., Edge, J., Short, M. J., Mundel, T. (2011). Intermittent- Sprint Performance and Muscle Glycogen after 30 h of Sleep Deprivation. Med. Sci. Sports Exerc., Vol. 43, No. 7, pp 1301-1311.

8. Dattilo, M., Antunes, H. K., Medeiros, A., Monico Neto, M., Souza, H. S., Tufik, S., de Mello, M. T. (2011). Sleep and muscle recovery: endocrinological and molecular basis for a new and promising hypothesis. Med Hypothesis 2011 Aug; 77(2): 220-2.

9. Besedovsky, L., Lange, T., Born, J. (2012). Sleep and immune function. Pflugers Arch. 2012 Jan: 463(1): 121-137.

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TREATMENT OF MENISCAL LESIONS IN PROFESSIONAL FOOTBALLERS FEATURE / K.BORQUE, M.JONES, M.LAUGHLIN, M.COHEN, D.JOHNSON & A.WILLIAMS Introduction Meniscal injuries in footballers are a common cause of missed game time and even have the potential to be career shortening. While the treatment approach must take into account the footballer’s position, time in season, and contract status, goals remain the same: achieving the quickest safe return to play while protecting the longterm health of the joint [1]. Historically, meniscectomy has been the treatment of choice for isolated meniscal tears in elite footballers, with repairs reserved for tears with concomitant ligament injuries [2,3].

With growing evidence of the potential short and long term negative effects of meniscectomy [4–6], especially of the lateral meniscus, treatment is currently evolving to include more meniscal repairs [7–9].

tibia [12]. Although shorter than many longitudinal tears, the longitudinal fibres of the meniscus are torn and the lateral meniscus loses function akin to total/ sub-total lateral meniscectomy [13].

It has previously been thought futile to repair these tears since only the peripheral portion of a radial tear has a good blood supply.

However, repair usually leads to healing and

decreased articular contact pressures, likely protecting the chondral surfaces in the short and long term [6,14,15]. For this reason, the authors strongly encourage repair of these tears in footballers. The authors prefer inside-out repair with a combination of vertical ‘rip-stop’ sutures either side of the tear spanned by an average of 3 horizontal mattress sutures as seen in Figure 2.

Medial Versus Lateral Meniscus Tears Across elite sport, lateral meniscectomies, compared to medial, have been shown to have increased post-operative effusions and missed game time [6], lower return to play rates [4], and are more career shortening even than ACL injuries [5].

Fortunately, Logan et al showed that lateral meniscus repairs heal at a higher rate than medial repairs in their elite athlete cohort [10]. Consequently, the authors strongly recommend repair of most lateral meniscus tears in footballers.

In contrast, most medial meniscectomies are tolerated well, at least in the short and medium term, by elite footballers [2].

This positive short-term outcome must be balanced against the development of medial osteoarthritis [11], although this usually develops after sports career end.

Tears of the Lateral Meniscus Longitudinal tears of the lateral meniscus For the reasons stated above, longitudinal tears of the lateral meniscus tears are always repaired, even if involving degenerative tissue.

The vast majority will heal well in athletes [10].

In contrast, there are frequent short and long term problems with lateral meniscectomy [6].

Radial tears of the lateral meniscus Radial tears of the lateral meniscus are most commonly associated with an ACL rupture, but isolated radial tears do occur. These tears decrease the contact area and increase contact pressures in the posterolateral

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Figure 1. Degenerative changes in the lateral compartment of the knee, the consequence of a partial lateral meniscectomy in a 23 year old professional footballer.

1 A &1B: Initial post-injury axial (1A) and coronoal (1B) images of a radial tear of the lateral meniscus (white arrows) in a professional footballer who then underwent partial lateral meniscectomy by a surgeon elsewhere before being referred for a second opionon.

1C: Coronoal image taken 2 months post-meniscectomy showing lack of meniscal engagement in tibio-femoral articulation and therfore lack of meniscal function 1D: Arthroscopic image of the lateral compartment 4 months post-meniscectomy, at arthroscopy undertaken for persistent knee swelling and inability to return to sport, showing significant chondral damage Images reprinted with permission from Springer. Borque KA, Jones M, Cohen M, Johnson D, Williams A. Evidencebased rationale for treatment of meniscal lesions in athletes. Knee Surg Sport Traumatol Arthrosc 2021. https:// doi.org/10.1007/s00167-021-06694-6.

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Complex tears of the lateral meniscus Based on the short and long-term negative effects of lateral meniscectomies, meniscal repair is considered even in complex lateral meniscal tears. The literature shows lateral meniscal repairs have higher rates of healing than medial meniscal repairs in both the isolated setting in elite athletes and when combined with ACL reconstruction in the general population [10,16]. In footballers, regardless of age, it is the authors’ view that repair should almost always be attempted even with tears traditionally thought to be unfavourable for suturing.

Anterior horn lateral meniscus tear The average human makes 1-2 million cycles of lower limb joint motion a year with running athletes undertaking many more. As a result, attritional damage to the menisci occurs. During knee flexion the lateral femur moves significantly posteriorly dragging the lateral meniscus with it, in contrast the medial femoral condyle moves much less [17]. The anterior horns of the menisci move more than their posterior horns, and thus the lateral meniscus anterior horn moves the most of all [18]. Therefore, it is not surprising that attritional longitudinal fissuring of the anterior horn of the lateral meniscus occurs so frequently that it should be viewed as ‘normal’ in the running athlete and only rarely needs surgical intervention.

On occasion these splits detach at one end and the fibres of the affected portion of the meniscus curl up forming a lump of meniscal tissue close to the anterior root which can irritate the fat pad in extension. The footballer will complain of anterolateral pain on knee extension which is especially problematic for striking a ball. Even in this situation surgery can frequently be avoided with an ultrasound guided injection of steroid to the affected portion of fat pad. If the footballer is unable to return to play following an injection and surgery is indicated, great care is taken to remove as little tissue as possible; only unstable prominent tissue is resected and the remaining fissures are then repaired if needed, but usually left alone.

Horizontal (cleavage tears) / lateral meniscal cysts These tears are the most common degenerative tears seen with elite footballers, whereas the normal population typically degenerative lesions are medial.

Such tears are often asymptomatic and should not be operated upon without good reason. If symptoms are present, they frequently relate to an associated

Figure 2. A complex, predominantly radial tear of the lateral meniscus in a 17 year old footballer 2A A radial tear between the anterior one third and posterior two-thirds of the lateral meniscus following gentle debridement of the tear to ‘freshen’ the tear and encourage bleeding 2B. Two vertical sutures (red arrows) were placed first to prevent pull out of the horizontal sutures 2C Four horizontal sutures were placed to reduce and compress the tear Images reprinted with permission from Springer. Borque KA, Jones M, Cohen M, Johnson D, Williams A. Evidencebased rationale for treatment of meniscal lesions in athletes. Knee Surg Sport Traumatol Arthrosc 2021. https:// doi.org/10.1007/s00167-021-06694-6.

Figure 3. A chronic complex tear in the lateral meniscal body of a 17 year old volleyball player 3A The tear pattern is delineated by the orange lines.

3B The chronicity of the tear is evident by the rounded edges of the torn fragment.

3C The longitudinal component was repaired first followed by repair of the radial component. Healing was confirmed by MRI 4 months post-operatively Images reprinted with permission from Springer. Borque KA, Jones M, Cohen M, Johnson D, Williams A. Evidencebased rationale for treatment of meniscal lesions in athletes. Knee Surg Sport Traumatol Arthrosc 2021. https:// doi.org/10.1007/s00167-021-06694-6.

cyst irritating the iliotibial band rather than the tear itself. In this scenario, the first step should be non-operative. With ultrasound scan guidance an experienced radiologist can not only inject the meniscal cyst with steroid or platelet-rich plasma, but also disrupt it with multiple passes of a large bore needle to break it down. It is rarely possible to actually aspirate the gelatinous material out of the cyst, but this is frequently not necessary for resolution of pain. Only when this treatment fails should surgery be considered. Excision of the degenerative tissue in the central meniscus body is performed with gentle application of a shaver inserted through the horizontal cleavage, followed by repair of the remaining meniscus if at all possible.

If resection is necessary, then that should be undertaken as sparingly as possible.

Posterior root lateral meniscus tear Posterior root tears of the lateral meniscus almost always occur with ACL ruptures and are more common in injuries sustained playing contact sports [19–21]. Due to

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their importance in load sharing, and their role in resisting anterior tibial translation and internal rotation, they should be repaired at the same time as undertaking ACL reconstruction [22–26].

Tears of the Medial Meniscus Isolated Longitudinal tears of medial meniscus Isolated longitudinal tears, including bucket handle tears, of the medial meniscus present the most difficult treatment decisions for clinicians involved in managing footballers.

On the one hand, partial medial meniscectomy leads to predictable and reliable high return to play (RTP) rates.

On the other hand, loss of meniscal tissue potentially leads to osteoarthritis in the long term [11]. The authors’ experience is that, in great contrast to footballers who have undergone lateral meniscectomy, it is very rare for a player to retire prematurely due to the arthritic consequences of medial meniscectomy.

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When making a treatment decision, factors such as tear distance from the periphery and athlete age impact healing and should be considered. Repairs of tears more than 4 mm from the periphery have shown higher rates of failure while repairs less than 2 mm from the periphery have shown increased healing potential [27,28]. Age is another factor with repair typically reserved for footballers younger than 18-20 years.

The decision to perform a meniscectomy versus repair must be made in combination with the footballer, discussing the shortand long-term effects of each option.

In contrast to isolated tears, due to much higher healing rates and the importance of the medial meniscus as secondary stabiliser aiding the ACL, longitudinal medial meniscal tears in the context of ACL reconstruction should be repaired.

Degenerative tears of medial meniscus Degenerative tears are generally found in the posterior third to half of the medial meniscus and have poor healing potential [27,29]. These are frequently noticed as incidental findings on an MRI undertaken for another complaint and as such should be left alone. Nevertheless, a minority are genuinely symptomaticespecially those with an unstable fragment lodged between the MCL and tibia. Initial treatment includes a short term of rest plus physiotherapy. If there is an effusion, drainage and injection of hyaluronic acid (HLA) and/ or platelet rich plasma (PRP) is considered [30]. Surgery is only considered after failure of non-operative measures and involves resection of as little tissue as possible.

Posterior root medial meniscus tear Isolated posterior root medial meniscus tears are uncommon, but untreated they can be devastating. The footballer often describes a twisting injury with the knee in a flexed position and may describe a ‘popping’ sensation. They tend to present with posterior pain in deep flexion, but little or no swelling, lack of joint line tenderness, and a negative McMurray’s sign [31]. Due to this, diagnosis can be difficult and high clinical suspicion is required. Medial meniscus posterior root repair restores the competence of the medial meniscus by addressing meniscal extrusion and should be attempted in all cases, even in the presence of established chondral damage [32].

chronic ACL injuries lead to medial meniscal tears [33], the authors have found that both medial and lateral meniscal pathology is frequently found in elite footballers with ACL tears, likely a reflection of the greater forces that occur at high levels of sport.

Repair of a meniscus tear in the setting of an ACL injury should be the first choice knowing the importance of the menisci as secondary stabilisers for the ACL [22,26,34– 37]. Meniscal integrity has been shown to be predictive of laxity and survivorship of the ACL graft following ACL reconstruction [38,39]. Fortunately multiple studies have suggested that meniscal repair is more likely to be successful when combined with an ACL reconstruction than when performed in isolation [28,29,40–42].

Biologic augmentation Healing of meniscal repair depends on vascularity in the menisci, which is best peripherally and least centrally. Tear preparation prior to attempting repair is very important and every effort is made to improve the biological environment to increase chances of healing. Based on current research, the authors routinely use a rasp and gentle application of a power shaver to the torn meniscus edges and adjacent synovium [43,44], inject PRP into the suture line using spinal needles [45], and undertake bone marrow stimulation through microfracture [46] of the lateral wall of the intercondylar notch in isolated meniscal repairs.

Post-operative Rehab Post-operatively full active and passive extension is encouraged immediately for all patients. Meniscectomies are allowed to weight bear as tolerated. The exception is when bone marrow oedema is present on MRI, in which case the footballer is limited to 3 weeks partial weight-bearing, after which full weight bearing is allowed once knee extensor

Concomitant meniscal tears with ACL Injury Meniscal injuries have been reported to occur in between 41% and 82% of ACL injuries with increased incidence noted with participation in contact sports [20]. While classical teaching states that acute ACL injuries result in lateral meniscus tears and

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strength has been restored [47]. In these cases, use of an ‘off-loader’ brace is considered.

For meniscal repairs, weight bearing status and range of motion is determined by the type of meniscus tear [48]. Repairs of radial tears and root tears are kept non-weight bearing for four weeks, followed by two weeks of partial weight bearing [48]. If coronal plane alignment is unfavourable then an off-loader brace is worn for weight-bearing activity until the end of 12 weeks from surgery. Longitudinal tears are allowed to weight bear as tolerated, as weight bearing compresses the tear.

Flexion causes posterior meniscal motion especially over 60 degrees, [17] therefore flexion is limited to ninety degrees for the first four weeks following most meniscal repairs. For radial tears and root repairs, as they are more vulnerable, flexion is limited to 60 degrees for four weeks followed by two weeks limited to 90 degrees.

As flexion causes posterior femoral translation, especially laterally, and on the medial side a posterior shift in joint contact area [17], loaded flexion exercises are limited to a maximum 60 degrees for 6 weeks and 90 degrees until the end of the twelfth week. Running typically starts at the end of the twelfth week with the goal of return to play at 16 weeks. For radial tears this is usually a month later.

Conclusion Meniscal injuries in elite footballers are a common and successful treatment requires the clinician to understand the player’s goals and needs, communicate effectively between all stakeholders, and a have knowledge of the challenges posed by the different types of meniscal tears seen in this population.

It is important to recognise the differences in ‘personality’ of medial and lateral tears evidenced in the literature and understand the differing approaches to treatment.

football medicine & performance

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[22] Shybut TB, Vega CE, Haddad J, Alexander JW, Gold JE, Noble PC, et al. Effect of lateral meniscal root tear on the stability of the anterior cruciate ligament-deficient knee. Am J Sports Med 2015;43:905–11. https://doi. org/10.1177/0363546514563910.

[9] Abrams GD, Frank RM, Gupta AK, Harris JD, McCormick FM, Cole BJ. Trends in meniscus repair and meniscectomy in the United States, 20052011. Am J Sports Med 2013;41:2333–9. https://doi. org/10.1177/0363546513495641.

[14] Scheller G, Sobau C, Bülow JU. Arthroscopic partial lateral meniscectomy in an otherwise normal knee: Clinical, functional, and radiographic results of a long-term follow-up study. Arthroscopy 2001;17:946– 52. https://doi.org/10.1053/jars.2001.28952.

[35] Zhang Y, Huang W, Yao Z, Ma L, Lin Z, Wang S, et al. Anterior cruciate ligament injuries alter the kinematics of knees with or without meniscal deficiency. Am J Sports Med 2016;44:3132–9. https:// doi.org/10.1177/0363546516658026.

[37] Musahl V, Citak M, O’Loughlin PF, Choi D, Bedi A, Pearle AD. The effect of medial versus lateral meniscectomy on the stability of the anterior cruciate ligament-deficient knee. Am J Sports Med 2010;38:1591– 7. https://doi.org/10.1177/0363546510364402.

[24] Perez-Blanca A, Espejo-Baena A, Amat Trujillo D, Prado Nóvoa M, Espejo-Reina A, Quintero López C, et al. Comparative biomechanical study on contact alterations after lateral meniscus posterior root avulsion, transosseous reinsertion, and total meniscectomy.

Arthroscopy 2016;32:624–33. https://doi.org/10.1016/j. arthro.2015.08.040.

[13] Ode GE, Van Thiel GS, McArthur SA, DishkinPaset J, Leurgans SE, Shewman EF, et al. Effects of serial sectioning and repair of radial tears in the lateral meniscus. Am J Sports Med 2012;40:1863–70. https:// doi.org/10.1177/0363546512453291.

[34] Ahn JH, Bae TS, Kang KS, Kang SY, Lee SH. Longitudinal tear of the medial meniscus posterior horn in the anterior cruciate ligament-deficient knee significantly influences anterior stability.

Am J Sports Med 2011;39:2187–93. https://doi. org/10.1177/0363546511416597.

[21] Feucht MJ, Salzmann GM, Bode G, Pestka JM, Kühle J, Südkamp NP, et al. Posterior root tears of the lateral meniscus. Knee Surg Sport Traumatol Arthrosc 2014;23:119– 25. https://doi.org/10.1007/s00167-014-2904-x.

[8] Sochacki KR, Varshneya K, Calcei JG, Safran MR, Abrams GD, Donahue J, et al. Comparing meniscectomy and meniscal repair: A matched cohort analysis utilizing a national insurance database.

Am J Sports Med 2020;48:2353–9. https://doi. org/10.1177/0363546520935453.

[12] Bedi A, Kelly N, Baad M, Fox AJS, Ma Y, Warren RF, et al. Dynamic contact mechanics of radial tears of the lateral meniscus: Implications for treatment.

Arthroscopy 2012;28:372–81. https://doi.org/10.1016/j. arthro.2011.08.287.

(ACL) ruptures and in chronic ACL-deficient knees: Classification, staging and timing of treatment. Knee Surg Sport Traumatol Arthrosc 1995;3:130–4.

[28] Cannon WD, Vittori JM. The incidence of healing in arthroscopic meniscal repairs in anterior cruciate ligament-reconstructed knees versus stable knees. Am J Sports Med 1992;20:176–81. https://doi. org/10.1177/036354659202000214.

[29] Noyes FR, Barber-Westin SD. Arthroscopic repair of meniscal tears extending into the avascular zone in patients younger than twenty years of age. Am J Sports Med 2002;30:589–600. https://doi.org/10.1177/03635465020300 042001.

[30] Strauss E, Hart J, Miller M, Altman R, Rosen J. Hyaluronic acid viscosupplementation and osteoarthritis: Current uses and future directions. Am J Sports Med 2009;37:1636–44.

[31] Evans PJ, Bell GD, Frank C. Prospective evaluation of the McMurray test. Am J Sports Med 1993;21:604–8. https:// doi.org/10.1177/036354659302100420.

[32] Witherow A, Young J, Myers P. Repair of posterior medial meniscal root tears in the setting of Outerbridge III and IV cartilage damage. Orthop J Sport Med 2017;5:2325967117S0019. https://doi. org/10.1177/2325967117s00195.

[33] Cipolla M, Scala A, Gianni E, Puddu G. Different patterns of meniscal tears in acute anterior cruciate ligament

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[40] Ahn JH, Lee YS, Yoo JC, Chang MJ, Koh KH, Kim MH. Clinical and second-look arthroscopic evaluation of repaired medial meniscus in anterior cruciate ligamentreconstructed knees. Am J Sports Med 2010;38:472–7. https://doi.org/10.1177/0363546509348102.

[41] Melton J, Murray J, Karim A, Pandit H, Wandless F, Thomas N. Meniscal repair in anterior cruciate ligament reconstruction: a long-term outcome study.

Knee Surg Sport Traumatol Arthrosc 2011;19:1729–34.

[42] Tenuta JJ, Arciero RA. Arthroscopic evaluation of meniscal repairs: Factors that effect healing.

Am J Sports Med 1994;22:797–802. https://doi. org/10.1177/036354659402200611.

[43] Ochi M, Uchio Y, Okuda K, Shu N, Yamaguchi H, Sakai Y. Expression of cytokines after meniscal rasping to promote meniscal healing. Arthroscopy 2001;17:724– 31.

[44] Uchio Y, Ochi M, Adachi N, Kawasaki K, Iwasa J. Results of rasping of meniscal tears with and without anterior cruciate ligament injury as evaluated by secondlook arthroscopy. Arthroscopy 2003;19:463–9.

[45] Everhart JS, Cavendish PA, Eikenberry A, Magnussen RA, Kaeding CC, Flanigan DC. Plateletrich plasma reduces failure risk for isolated meniscal repairs but provides no benefit for meniscal repairs with anterior cruciate ligament reconstruction.

Am J Sports Med 2019;47:1789–96. https://doi. org/10.1177/0363546519852616.

[46] Kaminski R, Kulinski K, Kozar-Kaminska K, Wasko M, Langner M, Pomianowski S. Repair augmentation of unstable, complete vertical meniscal tears with bone marrow venting procedure: a prospective, randomized, double-blind, parallel-group, placebo-controlled study. Arthroscopy 2019;35:1500– 1508.

[47] Moffet H, Richards C, Malouin F, Bravo G, Paradis G. Early and intensive physiotherapy accelerates recovery postarthroscopic meniscectomy: Results of a randomised controlled study. Arch Phys Med Rehab 1994;75:415–26.

[48] Noyes F, Heckmann T, Barber-Westin S. Meniscus repair and transplantation: A comprehensive update. J Orthop Sport Phys Ther 2012;42:274–90.

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OSTEOCHONDRAL LESIONS OF THE KNEE FEATURE / FOOTBALL ASSOCIATION MEDICAL SOCIETY Osteochondral lesions of the knee was the topic for the final FA Medical Society evening lecture of this 2021/22 season. This is a hugely important topic as the management of players with these injuries is notoriously complex and challenging. Below is summary of each speaker’s presentation for those that could not attend.

Radiological assessment of cartilage defects in the knee - Professor Rowena Johnson

to extrusion of the meniscus. On ultrasound one can note low echogenicity at joint margins, while a detached body tends to look white. MRI is the main imaging modality as it provides high-spatial resolution, multiplanar imaging and excellent tissue contrast.

Different imaging sequences can be used in MRI. T1 provides limited assessment of joint structures, while better contrast definitions are achieved with PDFS rather than with T2FS.

Hyaline cartilage is composed of a low density of chondrocytes surrounded by an abundant extracellular matrix of which approximately 80% will be water. This can act as a cushion distributing the impact of compressive forces with collagen fibers anchoring the underlying subchondral bone.

The main function of hyaline cartilage includes absorption and distribution of loading forces.

Imaging modalities to assess for osteochondral defects Radiographs tend to be the main imaging modality in epidemiological studies. On an X-Ray, cartilage cannot be seen unless calcified. A reduction in joint space tends to be secondary to cartilage loss but may be due

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Sensitivity of MRI may be reduced due to thick slices which may mask osteochondral lesions. Moreover, 3T provides greater spatial resolution when compared to 1.5T. Nuclear medicine imaging is used for troubleshooting in cases were athletes have adjacent abnormalities, with very few patients being selected for this imaging modality. Nuclear medicine imaging is used

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2.

The Outerbridge classification of chondral lesions is used in arthroscopy (see image below) and is a simple and reproducible grading system of articular cartilage lesions. The most reliable sign of instability within adults is if there is high signal at it’s base. On the other hand, for the paediatric / adolescent population tiny subchondral cysts is a potential sign of instability.

Take home messages: • MRI is the main imaging modality to assess for osteochondral defects.

• Proton-density fat saturation is the desirable MRI sequence as the fluid will show up as bright and allow for clear differentiation to the darker joint surfaces.

• The most reliable sign of instability within adults is if there is high signal at it’s base.

• The Outerbridge classification is a simple and reproducible grading system of articular cartilage lesions.

• Try not to re-image the knee too soon following surgery as the images will always lag behind and they will not look as good as you hope!

3.

Attritional Chondral Damage: Athletes overload their lower limb and may accelerate the process of OA formation. One needs to be aware of joint effusions which is a sign that the joint is not coping with the load or that there is knee joint pathology.

Exacerbating factors for this type of injury include inflammation, malalignment, meniscal deficiency, ligament deficiency and repetitive impingement (characteristically seen in javelin throwers). Moreover, steroids should not be used to overload the joint before its ready.

Meniscal deficiency: Lateral meniscectomy is less tolerated especially when players are in varus. This is because the lateral meniscus (LM) takes a greater proportion of the load through the joint and is very mobile. In view of this, whenever possible, lateral meniscal tears should be repaired. A study by Nawabi et al., 2014 (ASJM) noted that the median time to return to play, was longer in the lateral group than the medial group (7 weeks vs 5 weeks). Lateral meniscectomy

Surgical considerations for the professional footballer with an osteochondral defect- Mr Andy Williams

4.

Malalignment: Most footballers have retroverted hips driving the knees in varus which means an overload into the medial compartment of the knee. Return to sport after osteotomy is difficult but it helps to off load the joint.

5.

Ligament laxity: PCL deficiency results in point loading.

6.

Chronic repetitive impingement: Damage related to repetitive loading occurs due to anteromedial femoral impingement commonly seen in fast bowlers and strikers.

This can also be seen acutely with mechanisms such as knee hyperextension when landing from a header. If this doesn’t settle conservatively, then surgical options would be indicated such as debridement +/-microfracture bone procedure.

One must be wary of the “angry knee”. Carrying a persistent effusion within the knee is not normal and a knee with an effusion has reduced shock-absorption ability as the fluid within the joint is not as thick as a normal joint fluid. It also carries inflammatory mediators which again exposes the articular cartilage to further damage. Interventions to halt synovitis include rest, NSAIDS, PRP, intraarticular corticosteroids (used with caution with the player resting for a period of at least 3 weeks), and rehabilitation.

Genetics also play a role in the development of the angry knee.

Articular cartilage is an almost frictionless bearing surface with little healing capacity as it is aneural, avascular and without lymphatics.

Articular cartilage damage can be well tolerated with most cases not requiring surgery however symptoms experienced by the athlete include swelling, pain, locking, and instability. The severity of these symptoms may necessitate surgery. Chondral damage in athletes can occur secondary to direct trauma, attritional wear, osteochondritis dissecans (frequently present late as it’s normal for young footballers to feel pain) or osteochondritis which results in avascular necrosis (mainly secondary to overpressure).

1.

has a higher incidence of adverse events in the early recovery period, including pain, swelling, and the need for further arthroscopy. It is also associated with a significantly lower rate of return to play. These findings form the basis of an important discussion that must be had with the player and the club before a lateral meniscectomy is performed in elite soccer athletes.

fragment is noted or if the patient fails to progress and presents with persist synovitis. Another cause is an intra-articular fracture.

particularly in cases to assess whether the patient needs surgery or to highlight if the osteochondral lesion is in fact driving current symptoms. However, it is not a first line investigation.

Direct trauma: Usually associated with other injuries (e.g. ACL) but not all require surgery. Surgery would be indicated if a loose

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feature Take home messages: • Chondral lesions are normal in athletes and only a minority need surgery. It is important to treat the athlete and not the MRI, whilst doing as little as one can to achieve the desired result.

• Chondral damage in athletes can occur secondary to direct trauma, attritional wear, osteochondritis dissecans, or osteochondritis which results in avascular necrosis.

Surgical and orthobiological approaches to restore cartilage health Professor Bert Mandelbaum The prevalence of cartilage injuries has widely increased in the football population with the highest risk in elite players.

Furthermore, these injuries have become more prevalent in athletic population than in the general population (36% vs 18%).

Over time, loss of volume in articular cartilage has been noted.

Currently, an array of orthobiologics are being used including PRP, hyaluronic acid,

football medicine & performance and stem cell procedures. The data suggests that management of articular cartilage injuries of the knee is becoming more nonsurgical. Particulated Autologous ChondralPlatelet-Rich Plasma Matrix Implantation is a new and potentially exciting development in articular cartilage injury management.

In terms of resurfacing options there is no superiority, but they all appear superior to microfracture. Moreover, a femoral condyle and patella femoral algorithm has been developed which helps to make decisions based upon the size and location of the lesion (image below).

Take home messages: • Cartilage injuries have become more prevalent in athletic population than in the general population.

• Management of articular cartilage injuries of the knee is becoming more non-surgical.

• In terms of resurfacing options there is no superiority, but they all appear superior to microfracture.

Promoting Joint Health in the Ageing Footballer- Professor David Hunter Modern definitions of osteoarthritis (OA) describe OA as a disease of the whole joint, meaning even the synovial joint tissue can be affected.

1 in 8 adults suffer from OA, and because of changing demographics data demonstrates that OA is occurring earlier. In fact, the age at which people are becoming affected

by OA is getting younger, reducing from 69.4 years old to 55.8 years old in the space of just 20 years. Risk factors for Knee OA include obesity, previous injury, and occupation.

Most injuries can be prevented via neuromuscular training.

There is a big window for us to intervene and prevent disease progression. When diagnosing the disease this should be based on symptoms or signs while using EULAR or ACR criteria. History and physical examination are usually sufficient when diagnosing, as imaging may drive up rates of surgery. It is also useful to keep in mind that anxiety and stress can influence expression of pain and disability.

With regards to treatment for knee OA, most guidelines do not advocate for the use of PRP. Furthermore, the current recommendation is to restrict the use of mesenchymal stem cells to clinical research trials only.

With the use of DMOAD (disease modifying OA drugs) some structural modification was noted (increase in cartilage thickness) however, from a symptom point of view there was no improvement. Dietary supplements such as glucosamine and/or chondroitin are not recommended on current guidelines. The core treatment, as per guidelines, include education, self-management, physical activity and to maintain healthy weight.

Exercise should include strength, aerobic, stretching, and neuromuscular training at around 30 minutes per day.

Take home messages: • OA is a disease of the whole joint.

• Age in which people are being diagnosed with OA is getting younger.

• History and physical examination are usually sufficient when diagnosing as imaging may drive up rates of surgery.

• Treatment like PRP, dietary supplements like glucosamine, mesenchymal stem cells are not recommended on current guidelines.

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Clinical Psychotherapist, broadcaster, corporate coach and author ‘Why do players suddenly experience a catastrophic loss of form?’ [Online Presentation] 13th October 2022 | 7.00pm

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Freelance Clinician in Physiotherapy – ex Manchester United physio ‘Team Preparation in Professional Sport’ ‘The Importance of Clinical Skills in the Modern World’ ‘No Time to be Injured – Prequel and Sequel Included’.

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Head Physiotherapist for the Foundation and Youth Development Phases at Manchester United Football Club ‘Tackling Paediatric Injuries’ ‘Physiotherapy in an elite football academy: Beyond injuries!’

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‘BRIDGING THE GAP’ – THE ROLE OF INDIVIDUALISATION IN MANAGING THE PHYSICAL TRANSITION BETWEEN ‘PART-TIME’ AND ‘FULL-TIME’ ACADEMY FOOTBALL FEATURE / FRANCES HUNTER & JONATHAN TAYLOR Introduction In English academies the transition between the under 16 (u16) and under 18 (u18) age-groups (also representative of the part-time to full-time transition) observes a ‘two-fold’ increase in required coaching hours in accordance with the Elite Player Performance Plan (EPPP). Additional coaching contact times come s with greater physical and physiological demands, and if this transition is not managed correctly, overuse injuries and under performance are highly likely as a consequence (Gabbett et al. 2017). This is significant given that injury is negatively associated with player progression in academies (Larruskain et al. 2021). The substantial differences in training loads between u16, u18 and u23 age-groups in a Category 1 EPL academy were recently demonstrated (Taylor et al.

2022). Weekly total distance, high-speed running, ‘sprint’ distance (>25.2km.hr1), mechanical load and RPE-Loads were substantially higher in u18 in comparison to u16 players (Taylor et al. 2022) further highlighting the increased physical demand.

Evidence around injury incidence age-group comparisons is equivocal in high-level youth football. However, in a recent systematic review, u17 to u21 players were reported to have the highest injury incidence per 1000/h (7.9), with the probability of sustaining a time-loss injury 51-91% in u18 players, in comparison to wider probability range of 1-96% in u9-16 players (Jones et al. 2019).

Evidence around Injury burden (time-loss) is clearer, with u18 players reported to suffer the most severe injuries (Materne et al. 2021). Data on seasonal variation of injuries indicates that two ‘injury peaks’ occur (Read et al. 2017). The first peak occurs immediately post ‘pre-season’ during which physical stress is elevated (September), and the second following the ‘winter break’ where ‘deconditioning’ may occur (January).

Interventions Effectively managing the ‘transition’ requires an individualised approach to player development. This is of particular

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relevance during pre-season - immediately following the transition, and other periods where training load ‘spikes’ occur. Various approaches are used to mitigate the potential negative effects of the transition phase. Here we outline some of the strategies that can be used, whilst providing case-examples.

‘Pre loading’ within the final months (i.e., Apr-May) of the U16 training programme has been highlighted as a strategy to ‘bridge the gap’ (Taylor et al. 2022). This refers to the systematic build-up of training load in the months preceding the transition. However, academic pressures and low training adherence once player scholarships are awarded, might limit effectiveness of this method. Here, two alternative methods of individualising training that may facilitate the transition are detailed. The use of individualised speed zones has received increased attention over recent years and may be of use to help solve this puzzle. However, for the purpose of this article, we are going to focus on two interventions only.

Fitness Testing Results & Training Age: Physical testing batteries are commonplace in Academies that operate within the EPPP framework. Therefore, with appropriate test selection, testing data can be used to create sub-groups within the U18 age-group to individualise training prescription for players. It is widely accepted that players aerobic fitness (Gabbett et al, 2018; Malone

et al, 2017) and the age of athlete (Gabbett et al, 2017; Blanch et al; 2015) are moderators to tolerating training load. Therefore, accounting for these factors within a given intervention is intuitive. Table 1 demonstrates how Clubs may categorise players into groups based on Aerobic Fitness and age (training age).

In this example, the 30:15 Intermittent Fitness Test termination speed (VIFT) and training age score (see below), is used: •

U17 (recruited externally as a 1st year scholar) = 1

•

U17 (recruited internally as a 1st year scholar) or U18 (recruited externally from a part-time model) = 2

•

U18 (Graduated from U17s; or recruited from a full time Academy model) = 3

In this example, Group 2 players could complete the standard training programme employed by the coach and MDT staff at the start of the U18 season. Players in Group 1 and 3 would complete a modified & progressed programme respectively. The example below (table 2) presents what this could look like at Middlesbrough Football Club (we appreciate the nature of these modifications are club and resource specific). It should be noted that effective communication of these training differentiators and agreement between MDT is critical to the success of this model.

Table 1. Use of training age score (see above) and Aerobic Fitness to group player.

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football medicine & performance

Table 2. Possible Training modifications/ Training swaps for players identified as having training ‘gap’

Table 3. Example of Player Locomotor Profiles and compatible HIIT methods.

Player locomotor profiling - ‘Typologies’: Recently, Sandford et al. (2021) detailed the potential of the Anaerobic Speed Reserve (ASR) in understanding athlete locomotor profiles (which provide insight into muscle fibre typology) and the potential ‘responsiveness’ of athletes to different training modalities/formats. The anaerobic speed reserve defines the difference between athlete maximal aerobic speed (often estimated from continuous or intermittent tests in football) and maximal sprint speed (Sandford et al. 2021). This construct could also facilitate the identification of sub-groups, and enhance training prescription to facilitate the transition.

At Middlesbrough Football Club, the 30:15 IFT is used to profile aerobic fitness and MAS can be estimated as 87% vIFT (Taylor et al 2022). MSS is determined using the 20-30m split from a 30-m sprint (alternatively maximal velocity derived from GPS data achieved during training and match-play can be used). The example in table 3 demonstrates the diversity of locomotor profiles seen within team sport athletes. Further to this, Figure 1a and 1b shows a true representation of a U18 ASR (Figure

1a) and MAS and MSS (Figure 1b).

This profiling can be useful during the prescription of High Intensity Interval Training (HIIT), which is a frequently used tool at Middlesbrough FC. Specifically, it may allow the selection of an appropriate HIIT formats for each sub-group (Bellinger et al 2020), examples are presented in table 3.

These profiles may also be useful in prescribing game-based training to complement player profiles and maximise training benefits. For example ‘Speed’ players could complete 4v4 more SSGs e.g., 4v4 Work:Rest of 2 mins:2 mins x 6. In contrast, ‘Endurance’ players could complete more MSG and LSG e.g., 8v8 work:Rest of 8 mins: 2 mins x 3. It should be stressed, that all players should be exposed to a range of training methods/ formats, but an emphasis on the appropriate method could be used at different points in the season. With careful planning and dosing, it could be agreed and designed whereby all players complete the same training model by September. With only one conditioning day suited to their typology from this time point onwards.

On a separate note, Figure 2 nicely highlights how players tactical positions

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can predispose players to certain typology profiles. For 4 of the anonymised player profiles shown in Figure 2, we have added their tactical position (CF=Centre Forward, CB=Centre Back, CM=Centre Midfield & ST=Striker). Using FB as the example, positional demands require them to have sprint and endurance capabilites due to the need of them to overlap at high speed and recover at high speed, over varying distances, continually throughout the game. Therefore, this position could be classified crudely as ‘Hybrid’. For Clubs or Organisations that cannot facilitate regular testing, or need to categorise a player quickly, positional profiling may prove useful.

Conclusion This article outlines practical solutions to the ‘gap’ in training load seen between U16 and U18 age groups in Academy Football (Taylor et al 2022). The strategies outlined could be useful for practitioners to implement within their programming to try and help successful integration of players transitioning from a part time (u16) to a full time programme (u18). It is recommended that, these, or any intervention used, should be supported by commonly used subjective training load responses such as wellbeing / session RPE.

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football medicine & performance

Figure 1a. Shows the difference in absolute ASR (m.s) in a U18 squad and how ASR can be used to anchor typology profiles: ENDURANCE:>13.5km. hr, HYBRID: 13.5-15.0km.hr and SPEED: >15.0km. hr). This needs to interpreted with caution as does not show the contribution of both MAS and MSS. Figure 1b highlights this.

Figure 1b. shows the diverse spread seen within a U18 squad when players are represented as a relationship between their MAS and MSS. Figure 2. Player Locomotor profiles with player positions included.

1. Bellinger, P., Desbrow, B., Derave, W., Eline, L., Irwin, C., Sabapathy, S., Kennedy, B.,Craven, J.,Pennell, E., Rice, H., Minahan, C, 2020. Muscle fiber typology is associated with the overreaching response to overload training. Journal of Applied Physiology, 120 (4), pp.823-836.

Figure 1a.

2. Blanch, P., Orchard, J., Kountouris, A., Sims, K. and Beakley, D, 2015. Different tissue type categories of overuse injuries to cricket fast bowlers have different severity and incidence which varies with age. South African Journal of Sports Medicine, 27, pp.108–113.

3. Gabbett, T.J., Nassis, G.P., Oetter, E., Pretorius, J., Johnston, N., Medina, D., Rodas, G., Myslinski, T., Howells, D.,Beard, A. and Ryan, A, 2017. The athlete monitoring cycle: a practical guide to interpreting and applying training monitoring data. British Journal of Sports Medicine, 51, pp.1451–1452.

4. Jones, S., Almousa, S., Gibb, A., Allamby, N., Mullen, R., Andersen, T.E. and Williams, M., 2019. Injury incidence, prevalence and severity in high-level male youth football: a systematic review. Sports medicine, 49(12), pp.1879-1899.

5. Larruskain, J., Lekue, J.A., Martin-Garetxana, I., Barrio, I., McCall, A. and Gil, S.M., 2021. Injuries are negatively associated with player progression in an elite football academy. Science and Medicine in Football, pp.1-10.

6. Malone, S., Roe, M., Doran, D.A., Gabbett, T.J. and Collins, K.D, 2017. Protection against spikes in workload with aerobic fitness and playing experience: the role of the acute:chronic workload ratio on injury risk in elite gaelic football. International Journal of Sports Physiology Performance, 12, pp.393– 401.

Figure 1b

7. Materne, O., Chamari, K., Farooq, A., Weir, A., Hölmich, P., Bahr, R., Greig, M. and McNaughton, L.R., 2021. Injury incidence and burden in a youth elite football academy: a four-season prospective study of 551 players aged from under 9 to under 19 years. British journal of sports medicine, 55(9), pp.493-500.

8. Read, P.J., Oliver, J.L., De Ste Croix, M.B., Myer, G.D. and Lloyd, R.S., 2018. An audit of injuries in six English professional soccer academies. Journal of sports sciences, 36(13), pp.1542-1548.

9. Sandford, G.N., Laursen, P.B., and Bucheit, M, 2021.

Anaerobic Speed/ Power Reserve and Sport Performance: Scientific Basis, Current Applications and Future Directions. Sports Medicine, 51, pp.2017-2028.

10. Taylor, J., Madden J.L., Hunter, F., Thorne, B.J., McLaren, S.J. 2022. Mind the “Gap”: A Comparison of the Weekly Training Loads of English Premier League Academy Soccer Players in Under 23, Under 18 and Under 16 Age-Groups.

Journal of Science in Sport and Exercise. doi.org/10.1007/ s42978-022-00162-4 11. Taylor, J., Madden J.L., Hunter, F., Thorne, B.J., McLaren, S.J. 2022. Mind the “Gap”: A Comparison of the Weekly Training Loads of English Premier League Academy Soccer Players in Under 23, Under 18 and Under 16 Age-Groups.

Journal of Science in Sport and Exercise.

Figure 2

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THREE P’S OF PRODUCTIVE PERFORMANCE

Education Co-Ordinator: Kevin Paxton

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AN INTRODUCTION TO KEY ISSUES IN FOOTBALLER WELFARE FEATURE / KIRSTY BURROWS 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.

INTRODUCTION From grassroots to the professional game, football is enjoyed by millions of people around the world. FIFA estimates that there are at least 128 million professional players, and a staggering 5 billion consider themselves football fans1,2.

Football embodies the spirit of a sport which belongs to society - embedded within the psyche of cultures and communities.

Its popularity, from grassroots to elite, reflects the beauty and commonality of a game which has the power to intrigue, transcend, unite, and drive change.

However, football, as with all sport, is a microcosm of society itself. And whilst it has the potential to raise awareness of complex socio-cultural issues and create positive change, these issues may also be magnified or even perpetuated through the sport itself.

Here we look to highlight several key issues impacting footballer welfare and focus on the positive impacts that tackling these issues in and through football can have on wider society.

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RIGHTS OF FOOTBALL PLAYERS Although the benefits of football participation are wide and varied, it is evident that players’ human rights may be infringed upon as a direct or indirect consequence of playing sport.

These violations include issues related to the protection of privacy, freedom of expression, prohibition of inhuman or degrading treatment, prohibition of discrimination, and the right to an effective remedy.

It is the responsibility of all those working in football, at every level and in every capacity, to foster sporting environments which recognise and protect the rights of all players - whether they are children in a local league or elite players on the World Cup stage - and to project these values across the fanbase.

This understanding is reflected in article three of the FIFA statutes (2019)3 which states that “FIFA is committed to respecting all internationally recognised human rights and shall strive to promote the protection of these rights”. These rights are inherent to us all, regardless of nationality, sex, national or ethnic origin, colour, religion, language, or any other status4.

There is often a perception that a rightsbased approach to athlete welfare is not compatible with elite sporting success.

This may be compounded by the hypercommoditization of players – once defined as “the extraction of economic and performance value to the point where athletes become indistinct and

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interchangeable”5 – which runs counter to the principle that football players are people first.

The possibility of substantial financial gains earned by and accessible to the upper echelons of the professional game should not create a pretext for environments where rewards and results are valued above a player’s fundamental rights.

Evidence demonstrates that a holistic approach to player welfare benefits the well-being of players and can influence the perception of sport as a whole - and its subsequent power to be a vehicle for positive societal change.

It is important to note that violations of the rights of football players do not stem from one specific aetiology – similarly to considering how the rights of any person may be infringed, it can come down to a myriad of factors.

In this article we acknowledge the right of all players to train and compete in environments which protect, respect and safeguard the integrity and dignity of others, starting specifically with the requirement to refrain from: 23.3: all forms of physical or mental abuse, all forms of harassment, and all other hostile acts intended to isolate, ostracize, or harm the dignity of a person; and 23.4: threats, the promise of advantages, coercion and all forms of sexual abuse, harassment and exploitation are particularly prohibited.

Article 23; FIFA Code of Ethics6

football medicine & performance SAFEGUARDING IN, THROUGH, AND AROUND FOOTBALL SAFEGUARDING The proactive action to protect people from harm or abuse through appropriate prevention and response measures and promoting their wellbeing. It means doing everything possible to identify and address risks and to prevent any kind of harm or abuse from happening such as physical, sexual, emotional abuse and neglect, trafficking and exploitation.

It also means having appropriate systems in place to adequately address and respond to concerns.

FIFA Guardians7

Harassment and abuse in all its forms is widespread and pervasive. Data demonstrates that across their lifetime, 1 in 3 women are subjected to physical or sexual violence (this does not include sexual harassment)8. These figures led the WHO Director General to comment that ‘Violence against women is endemic in every country and culture’, noting that this has only been exacerbated by the COVID-19 pandemic9.

Research further indicates that at least 1 in 6 men have experienced sexual abuse or assault10, whether in childhood or as adults; and international studies reveal that nearly 3 in 4 children aged 2-4 years regularly suffer physical punishment and/or psychological violence at the hands of parents and caregivers11.

Whilst there is no conclusive evidence demonstrating that abuse occurs more often in sport than elsewhere, there are factors which may increase risk within sport, including reward structures centering on a win-at-all-costs mentality, the hierarchical nature of sport, lack of protection policies and access to effective remedy, institutional scandal avoidance, and unbalanced gender ratios.

Whilst it is difficult to obtain precise data related to the prevalence of harassment and abuse in sport (and there is a dearth of literature examining football specifically), it has been clearly shown to occur in all sports disciplines, at all levels, and worldwide.

In a study of children and young people’s experiences of participating in organised sport in the UK, 75% of the 6,000 respondents (of which 13% said football was their main sport and 8% said it was their second) reported having experienced

emotional harm, 24% sexual harassment, 23% physical harm and 3% sexual abuse13.

fostering inclusion, community and driving wider social agendas.

A study of elite athletes and coaches in Zambia (of which 23% were footballers) found 78% reported having experienced verbal harassment, 69% sexual harassment, 65% neglect, 30% physical abuse, and 37% sexual abuse14.

Examples of sport for development programmes utilizing football to tackle wider societal issues are many and include the STOP GBV campaign implemented

by Sport in Action in Zambia17 which uses community football as a platform to integrate sport and anti-genderbased violence education, and Slum Soccer18, which uses football to foster sustainable development within otherwise marginalised populations in India.

There are countless opportunities for football to be used as a medium for social development, however these opportunities can only be realised when participation in the sport represents a physical and psychological safe space, centralising both the rights and welfare of participants across all levels of the game.

In a Canadian study of 1,001 current and retired professional athletes - including footballers - 60% reported having experienced emotional harm, 16% physical harm, 20% sexual harm and 71% neglect15.

It is also important to challenge the notion that harassment and abuse in sport predominantly impacts women and girls. A study by Rhind (2014)16 which reviewed cases of abuse in UK sport (and included football) found that 65% of the victims were male.

As cases of harassment and abuse in football have continued to come to the forefront of public attention over the past few years, it is important to highlight that more cases being reported within the sport does not point to harassment and abuse being more prevalent in football than in other sports or societal sectors.

In the face of historical evidence of systemic failures amongst sports organisations to prevent and/or respond effectively and appropriately to athlete maltreatment, disclosures reflect an active demand from players for safe, inclusive sporting cultures which recognise that their rights and well-being are of central importance.

To better protect and support all players, football organisations must build capacity in both the prevention of and the response to abuse in sport and ensure a trauma-informed, people-centered approach to working with survivors. It is also essential that the interventions put in place (such as organisational policies ensuring access to recourse and remedy, education and training, etc.) are regularly monitored and evaluated. FIFA has recently launched several important programmes to support this, most notably the FIFA Guardians programme7.

That said, football is also a powerful vehicle which can influence the realisation of the rights of children and other vulnerable groups around the world. For many, it represents a safe space - an opportunity for social development programmes and educational initiatives

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ACCESS AND OPPORTUNITIES FOR WOMEN AND GIRLS As previously noted, harassment and abuse can affect anyone in sport - with elite athletes, children, players with disabilities and LGBTQI+ athletes being amongst those at higher risk19. Similarly, anyone can be a perpetrator, however male-dominated gender ratios in sport have been evidenced to be a risk factor, and studies have indicated that a higher percentage of perpetrators of interpersonal violence in sport are male20.

When considering grassroots participation, women and girls may overwhelmingly face challenges related to access.

These have been broadly grouped as 1. practical – such as access to facilities, safe transport, funding, childcare, and personal safety in and around sports and community venues: 2. personal – such as clothing and equipment: 3. social and cultural - including gender constructs, attitudes and prejudices around sexuality, disability, and ethnicity, and 4. drop out due to harassment and abuse21.

This adds to the abundance of reasons why, when looking to cultivate safe and inclusive environments in and through football, it is essential to consider access and opportunity for women and girls from the pitch to the board room of the people’s game.

Women’s football has come a long way since its 12-team 1991 World Cup. With over 200 national teams globally and a planned 32-team World Cup in 2023, the momentum of women’s football can neither be denied nor ignored.

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It is estimated that 29 million women and girls play football worldwide and FIFA aims to reach 60 million by 202622.

Opportunity for women and girls in football is a multifaceted ecosystem that needs to be addressed at all levels. There is currently a vast underrepresentation of women among coaches (7%), referees (10%), and executives (9%) across all national football associations23. As an example, in Spain there were 44 UEFA Pro licenses given to women coaches in 2017, and 2,379 were given to men24.

Associations and clubs around the world are also recognising that investments should be made in facilities and in access to medical care. For example, FIFA’s Benchmarking Report: Women’s Football showed that clubs with better access to higher number and quality facilities outperform other clubs in their league, with 50% of teams with access to a set standard of quality facilities being their league champions in the last 5 years25.

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The 2020 FIFPro “Raising Our Game Report“26, which provides an overview of the global women’s football industry, issued a call to action for “fair treatment, decent work, equal opportunities and the right to viable career paths as professionals in this industry”, requesting the establishment of standards for the working conditions of players; global minimum labour standards; global standards for international tournaments and recognition of the professional status of players.

•

In 2017, Lewes FC became the first professional club to establish the ‘Equality FC’ agenda, which has reaped benefits ever since. Attendance quadrupled and additional sponsorship deals were made based on the club’s principles and values28.

•

In August 2019, Stephanie Frapport became the very first women’s referee to officiate a major men’s European final, the UEFA Super Cup29.

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Autumn 2021 saw the kick-off of the first fully professional women’s football league in Japan. The founding 11 teams of the WE League (Women’s Empowerment League) are required to have a stipulated minimum number of players on professional contracts; at least 50% of the staff must be female; and at least one woman on their executive board30.

•

FIFpro, together with Women in Football, also launched ‘Ready to Board’ in 2021 - a programme looking to equip and prepare 12 women for executive roles in professional football31. Even as we appreciate the advancements made in recent years, we must also acknowledge that there is still much work to be done. As passion and excitement for women’s football continues to grow at all levels, it is imperative that we continue to advocate for access, opportunity, and representation across the entire ecosystem.

ADDRESSING RACISM IN AND THROUGH FOOTBALL Football has many powerful societal benefits including fostering a sense of belonging, solidarity, teamwork, and community. Despite this, it may also reveal deeply embedded discriminatory undertones within society.

Methods to challenge the status quo have been practiced around the world.

Examples include the US women’s team taking legal action, stating the violation of the US Equal Pay Act and Ada Hegerberg, the first recipient of the Ballon d’Or Féminin, refusing to play for her national team in the 2019 World Cup due to disputes over equality27.

Incidents of racial abuse in football are not uncommon and sadly continue to be on the rise. The latest statistics from Kick it Out reported racial abuse in the professional game had risen by 53% from the 2018/19 season to the 2019/20 season regardless of the impact of COVID-1932.

In Italy, statistics from the Observatory on Racism in Football, found that there were 249 racist incidents in stadiums from 2011-2016, and in the 2017-18 season alone there were 60 reported incidents33.

Progression and change achieved by associations, clubs, technical staff, and players should, however, be noted.

Footballers are not only targeted on the pitch. Social media has given perpetrators a new avenue to reach (and abuse) the

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football medicine & performance

Football has many powerful societal benefits including fostering sense of belonging, solidarity, teamwork and community. Despite this, it may also reveal deeply embedded discriminatory undertones within society.

biggest names in sport whilst granting them a perceived sense of anonymity.

Between 17 and 26 June 2020, the Professional Footballers’ Association and Kick It Out, found that 43% of Premier League players had experienced racist abuse on Twitter34. Data collected by the English Premier League to monitor the issue of online harassment against players in 2021 suggested 70% of the profiles of perpetrators belong to people outside of the United Kingdom, demonstrating the international scope of online abuse35.

Whilst efforts are being made to tackle this behaviour (including educational & social campaigns and organisational responses in the form of sanctions), it is important to recognise racial inequality within the wider ecosystem of football itself.

In the UK, football was historically perceived as a white man’s sport and racial chants during football games were not uncommon36.

In Brazil, football at its origin was a sport for the elite. Games were played in exclusive clubs, and although admission to these clubs were primarily based on socioeconomic status, people of colour were informally banned from these locations37.

This has – thankfully – rapidly changed, and football has been shown to be an important platform for community

integration. However, a recent Belgian study highlighted a continued clear under-representation of minority groups within football’s governing organisations including coaches, technical staff, governance, and leadership positions38. This finding is supported by the 2017 Sport People’s Think Tank report which found that in 2017 people from ethnic minority backgrounds held only 4.6% of senior coaching positions in elite English football, despite accounting for 14% of the British population39.

Addressing racism in football will take more than legal, judicial, and disciplinary measures. Whilst these are necessary and should be applied consistently, properly addressing racism in football requires continued vigilance from every individual involved in the sport, from the tops of football organisations to fans watching at home. Diversity and inclusion strategies which recognises, and counters historical, social, and cultural prejudice must be embedded across all levels of the sport.

“Tackling racism in football involves confronting institutional racism, systemic prejudice, toxic behaviours and unconscious biases across society for change within and beyond sport.”34

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THE PROTECTION AND PROMOTION OF MENTAL HEALTH AND WELL-BEING When looking at the welfare of football players, it is crucial to discuss the intersectionality with mental health and well-being and the importance of caring for mental health with the same consideration as physical health.

In a study on mental health in elite footballers, Gouttebarge (2018) found a 4-week prevalence of symptoms of common mental disorders in elite football players ranging from 9% for adverse alcohol use to 38% for anxiety/depression, and the 12-month incidence ranged from 12% for distress to 37% for anxiety/depression40.

In recent years, we have seen many footballers speak up about the mental health challenges they faced both during their sporting careers and following their transition out of elite competition.

The stressors in today’s game are wide and varied, and include biological, psychological, social, sport-specific and career-related stressors40, and yet conversations concerning mental health and well-being are often shrouded in stigma, with players encountering a number of barriers to help seeking, including:

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• • • • • • •

Lack of problem awareness Scared of what might happen Impacts on ability to play or train Difficulty or unwillingness to express emotion Not sure who to reach out to Accessibility to support Belief that it would not help41.

Athletes experience mental health symptoms and disorders at similar levels to wider society41, and normalising conversations around mental health, recognising its importance to wellbeing and supporting help-seeking through established pathways to care will not only benefit football players, but also send an important and positive message to those for whom players are an important role model.

If we are to propagate a holistic approach to athlete welfare, we must recognise that mental and physical well-being are two halves of a whole.

CONCLUSION Whilst efforts are being made to ensure that football is a safe and inclusive sport which provides equal access and opportunity and in doing so demonstrates a commitment to wider social agendas, it is clear

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that further attention must be paid towards the protection and promotion of footballer welfare.

The issues discussed here demonstrate the need for a transcultural approach which recognizes the inter-related experiences of players who experience harassment, abuse, and discrimination – be it by gender, race, or any other protected characteristic - along with the mental, physical, and psychosocial well-being of football players.

A commitment to diversity and inclusion – from the pitch, across all functional areas, and reflected centrally in the leadership – would positively impact all key topics discussed in this article, as would ensuring that footballers have mechanisms to make their voices heard and are represented at the decisionmaking level of organisations.

Only by taking a holistic, rightsbased approach to fostering a culture which protects and promotes the physical and psychological well-being of football players across the entire football ecosystem can we influence social and cultural change and help to protect not only the physical and

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emotional integrity of players, but the values of the sport itself.

Whilst this article has provided an overview of some of the ‘hot topics’ currently impacting footballer welfare, they are by no means the only issues of note. Other topics including labour, economic exploitation, freedom of expression, specific considerations and protections for children, LGBTQI+ footballers and those with disabilities, and the rise of eSport and the implications for gamer welfare, warrant further discussion.

Acknowledgements: Carrie RaukarHerman, Tessa Jansen and Matthew Walker, Sports Rights Solutions

Kirsty Burrows M.D., F.E.B.S.M. Managing Director Sports Rights Solutions London, United Kingdom

Contact: kirsty@sportsrightssolutions.com

football medicine & performance

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Tilburg Law Review, 25(1), pp.12-26. Available at: https://tilburglawreview.com/articles/10.5334/ tilr.190/ 24. statista.com, (2020). Number of coaches with a UEFA pro license in national football associations in Europe in 2017, by gender. [online] Available at: https://www.statista.com/statistics/1006758/ uefa-pro-licence-coaches-europe-by-gender/ 25. FIFA (2021). Setting the Pace - FIFA Benchmarking Report, Women’s Football. 1st ed. [pdf] Zurich. Available at: https://digitalhub. fifa.com/m/3ba9d61ede0a9ee4/original/ dzm2o61buenfox51qjot-pdf.pdf 26. FIFPRO, (2020). Raising our Game - Women’s Football Report. [pdf] Hoofddorp. Available at: https://www.fifpro.org/media/vd1pbtbj/fifprowomens-report_eng-lowres.pdf 27. Rathbone, K. (2019). The gender pay gap for the FIFA World Cup is US$370 million. It’s time for equity. The Conversation, [online] Available at: https://theconversation.com/the-gender-pay-gapfor-the-fifa-world-cup-is-us-370-million-its-timefor-equity-118400 28. Salley, E. (2021). Lewes FC: How the club is disrupting the status quo in football | Under the Spotlight. Give me Sport, [online] Available at:

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38. Heim, C., Corthouts, J., and Scheerder, J. (2018).

Black footballers and coaches between white lines.

A multi-level analysis of racism and anti-racism CSR movements in Belgian football. In : T. Busset, B. Fincoeur, amd R. Besson. eds., En marge des grands: le football en Belgique et en Suisse. Peter Lang, pp 183-209. Available at: https://lirias. kuleuven.be/retrieve/52417 39. The Sport People’s Think Tank, (2017). Ethnic Minorities and coaching in elite football in England: 2017 update. [pdf] SPTT, Fare network, University of Loughborough. Available at: http://thesptt.com/ wp-content/uploads/2017/11/2017-SPTT-reportprint.pdf 40. Gouttebarge, V. and Kerkhoffs, G. (2018).

Mental Health in Professional Football Players. In: V. Musahl, J. Karlsson, W. Krutsch, B. Mandelbaum, J. Espregueira-Mendes, P. d’Hooghe, eds. Return to Play in Football. Berlin: Springer-Verlag, pp.851859. Available at: https://www.researchgate. net/publication/323807558_Mental_Health_in_ Professional_Football_Players 41. International Olympic Committee (2021). IOC Mental Health in Elite Athletes Toolkit.1st ed.

Lausanne: International Olympic Committee. [pdf] Available at: https://stillmed.olympics.com/media/ Document%20Library/IOC/Athletes/Safe-SportInitiatives/IOC-Mental-Health-In-Elite-AthletesToolkit-2021.pdf

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EURO 2020: HOSTING A MAJOR FOOTBALL TOURNAMENT DURING A GLOBAL PANDEMIC – THE UK PERSPECTIVE FEATURE / STEPHEN BOYCE & MIKE PATTERSON Despite Scotland and England being part of the UK on the global stage, Scotland has its owned devolved government. Covid restrictions and public health guidance was different between Scotland and England. This led to significant problems in planning for the tournament, for UEFA, the national teams, and both UK CMO’s.

Following the declaration of the covid 19 global pandemic the UEFA European Championships due to be held in the summer of 2020 were postponed by a year to 2021. These championships were to be different. Instead of one large country or two smaller countries co-hosting the event, UEFA had awarded the tournament to eleven cities across Europe. The idea was to provide an opportunity for smaller nations to host part of a major football tournament that would otherwise not have the resources to do, bringing live matches to a larger fan base. The semi-finals and finals were to be held at Wembley stadium in London.

Glasgow Four matches were scheduled to take place at Hampden Park, Glasgow; three group matches and a last 16 knockout match. UEFA have a list of medical regulations required for hosting a tournament. This involves the stadium (players and crowd), training venues, team hotels, referees, VIPs, staff, and major incidents. The Glasgow medical plan had been prepared by Dr John Maclean in 2018/2019. Due to the Scotland national team qualifying for the tournament, he stepped down as CMO to concentrate on his role as national team doctor and I took over the CMO role in January 2021 at the height of covid, with Scotland under significant government restrictions. A comprehensive medical plan for all aspects

The logistics of organising a transcontinental tournament would be challenging in normal circumstances, however, the addition of covid measures increased these difficulties significantly. International travel, government restrictions and public health legislation varied across European countries, and even within sovereign states.

The governance of the tournament consisted of an overall CMO in charge of the tournament appointed by UEFA, with a CMO appointed for each host city. Following the introduction of covid travel restrictions, the CMO’s could not meet in person, with meetings coordinated by the UEFA medical department via video conference. I was appointed the CMO for the Glasgow and Mike Patterson the CMO for London.

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of the tournament at Glasgow now required the addition of covid mitigation measures.

Covid restrictions in Scotland were different to England throughout the pandemic. The differences in each nation’s public health approach reflected epidemiology, public health strategy, and the complex political landscape between UK central and devolved governments.

All of this needed to be presented in a unified way to the national participants and UEFA by the UK CMOs. UEFA asked for guarantees that the tournament would take place in June 2021. The Scottish Government could not provide these guarantees and it wasn’t clear if the tournament would take place in Glasgow. Two host cities, Dublin, and Bilbao had their matches moved to alternative venues as the respective governments could not provide these assurances. After many meetings with the Scottish Government, public health authorities and the local organising committee (LOC), the Scottish Government finally agreed at the end of March 2021 that the tournament would take place. The number of fans allowed inside the stadium and covid mitigation procedures had still to be agreed.

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At this time covid public health restrictions were different in Scotland and England. These encompassed the following: •

Entry requirements into the country regarding PCR testing, previous covid infection and the use of lateral flow tests

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Definition of a close contact

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Isolation time for positive cases and close contacts

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Social distancing

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Face mask wearing

•

The public were subject to different rules regarding households’ gathering, the opening of shops, restaurants, hotels and licenced premises.

The national teams scheduled to be based in Scotland were Croatia, Czech Republic, and Scotland. Croatia planned on a base in St. Andrews, the Czech Republic in Edinburgh.

Scotland, qualifying later via the delayed play-offs route, had chosen the North of England as their training base. These national teams would also travel to England to play one group match at Wembley.

Explaining the difference in covid restrictions to representatives of national teams at the

site visits caused confusion. Despite being resident in one country, the UK, they would be required to adhere to a different set of covid rules at their base camp in Scotland, compared to the hotel base prior to their match at Wembley.

Concerns were raised about the rigidity of covid testing and restrictions in Scotland, with the main contentious point around the definition of a “close contact”. Players and staff would be tested every 72 hours.

A close contact was defined as “within 2 metres for more than 15 mins” in Scotland.

Isolation was a legal requirement in Scotland. The national teams concluded they would require a minimum of six buses to travel to training and matches to avoid having players potentially being considered a “close contact” of any positive case. England had different regulations including exemptions and “research” options in elite sport. I was asked a valid question that I couldn’t answer; “why is the Scottish national team staying in England and not their own country?” .

Despite intensive discussion with public health authorities, I could not achieve exemptions from these rules for the “national team bubbles”. After discussion

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with UEFA, Croatia, and the Czech Republic, it was agreed these nations would remain in their own countries and travel to Scotland for matches. This way they would be subject to their own national public health legislation. They would travel 48 hours before the match having performed PCR testing in their own country and leave immediately after the match to travel directly home. The team services department had worked for several years arranging tournament logistics for the national teams, e.g., hotels, training venues, transport, to have this work no longer needed.

The tournament took place with only 20% of fan capacity at Hampden Park, Glasgow due to covid social distancing rules. National teams travelled in and out of Glasgow airport, turning travel operations into a less than 48 hour trip to the UK with the constant fear of delays and extra testing. No testing of the teams occurred in Scotland, only the LOC staff. In the end this actually worked well, removing the logistical difficulties of medical staffing for training venues and hotels, requiring only the 48 hour period of stay in Glasgow to be covered.

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London Wembley Stadium hosted eight matches in the tournament, including both semi-finals and the final. One match scheduled for Dublin prior to the pandemic increased the originally planned seven events. The Football Association (England) has staff in employed roles that include delivery of medical care in tournaments; including stadium clinical care, venue medical operations, team medical liaison and an over-arching CMO role. Having recently delivered the U17 EUROs and Champions League Final, and with an established stadium medical team already part of The FA staff, we were able to up-scale our normal operations to deliver the required UEFA medical requirements.

Having already designed a detailed medical strategy, we started planning how this would be implemented in the COVID-19 pandemic.

A major component of our planning was developing strategies to meet the healthcare needs of the high volume of personnel, both playing and otherwise participating in the delivery of the tournament, in London.

A combination of strict travel restrictions and quarantine for everyone but players and technical staff, and the last-minute decision by participating teams to remain in basecamps at home and fly in for less than 48 hours, led to the overall healthcare burden of the tournament reducing enormously, so the majority of our planning was focused on the implementation of COVID-19 rules.

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The only remaining national authority we were to host was the Scottish national team; the strong links and excellent working relationship we already had in place with our healthcare professional colleagues made what could have been a difficult situation relatively straightforward, even in complex and contentious case management. From the period leading up to the tournament, and throughout its delivery, we would be in almost constant contact with one another and our UEFA CMO colleague.

As far as delivery on the ground, all the FA tournament medical team had worked as frontline staff in London during the pandemic. They had then gone on to work with the team delivering football matches from behind closed doors to matches with limited spectator numbers at Wembley and other venues.

We relied heavily on this experience and our close links with UK government and local public health authorities.

A major difference between the experience in London and our colleagues in Glasgow was the increasing spectator attendance at Wembley due to our participation in the UK Government’s Event Research Project (ERP).

This allowed us and other event providers to participate in developing new protocols to manage the safe return of the public to sports and cultural events. Wembley was the only major stadium participating, and in conjunction with our events delivery team,

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the local authorities, and the associated government departments, we developed novel crowd management models and ventilation systems to augment social distancing guidelines and implemented a system that integrated mass testing and vaccination certification into our normal ticketing and stadium access protocols.

This project allowed us to escalate the spectators attending Wembley through processes tested prior to the tournament at our traditional end-of-season cup finals, and include a tapering up of spectator numbers through the tournament, with 25% capacity for the group stage and first R16 games, 50% capacity for the next R16 game and 65% capacity for the semi-finals and 100% capacity for the final at 88,000.

During the tournament we worked with public health colleagues in central UK government, local authority and regional health protection teams. When notified of COVID19 cases pre-ordained protocols were used to ensure ongoing safety in the affected cohorts, gather information for the identification of close contacts to support the public health authorities, and advise affected individuals to ensure compliance with law. We co-ordinated additional testing with laboratory partners alongside stringent regular PCR testing protocols that were required for participation in the tournament. COVID19 case management was the daily reality of running the tournament, and the case management

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system was used for a whole range of staff and participants, from Fan Zone volunteers, venue security staff, broadcasters, to national governing body staff and players.

One significant difference in the COVID19 case management experience between London and Glasgow was the participation of the London medical team in a Public Health England research study into the utilisation of regular testing and monitoring of elite sports individuals who had been allocated low risk close contact status from a COVID19 case. This allowed us to adopt daily medical assessments with rapid antigen testing (at that time an emerging technology), to safely allow continued participation in the competition. This was only available to key, mission critical personnel and players, who were living within the managed risk environment “bubbles”.

This allowed a number of games to continue without major last minute disruption and did not lead to any adverse cases.

covid pandemic demonstrated the differences in approach of the four home nations and within English regions.

For UEFA, rules were different in other countries too with full stadium attendances in Budapest compared to 20% capacity in Glasgow.

What lessons could be learned away from politics? In a sporting event of this size taking place in the UK during a pandemic, more opportunity should have been provided for public health authorities to play a prominent role in the organisation of tournament covid rules, communicating directly with each other and not via intermediaries, namely the CMO’s, who are not public health

Conclusions Both CMO’s kept in close contact throughout the preparation and competition phase. We endeavoured to provide one answer where possible, but were both subject to the rules and regulations set by the Scottish and UK governments. It is easy to understand why UEFA and national teams expected the UK to operate under one set of rules, but the

specialists. We were appreciative of the assistance and support that we received from individual personnel within our public health authorities, who provided a practical common sense approach tailored to sport when needed, supporting us in our CMO roles. Irrespective of pandemics, a public health medicine specialist would be a valuable addition to the senior medical team involved in major tournament planning, with protected time provided by the employing authorities to this role.

The constant changes in the political landscape across Europe and within the UK regarding the hosting of the event was frustrating. Of course it was extremely difficult to plan forwards at the height of a pandemic with pressing health matters prioritised over a football tournament. However, the bureaucracy of decision-making needs streamlined.

These events involve multi-agency partnership working but require timeous accountability in the final decisionmaking process to allow complex infrastructure organisation to proceed.

Acknowledgements We would like to thank our respective medical teams, public health personnel and the UEFA medical team, for their help and assistance in ensuring the delivery of an excellent football tournament despite the numerous challenges we all faced.

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