Issue 42 - Spring 2023

football medicine & performance

In this issue

Injuries In Professional Football - Shouldering the Burden

Bringing well-being into the performance picture

Ultrasound Assessment of Hamstring Muscle Architecture – The link to injury

Tactical periodisation in football

Sport-Related Concussion in High School Soccer

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“Phones are for calling people and cameras are for taking photographs”, lamented one member;

“We should all work together and be able to do much the same work as each other”, suggested another.

The underlying question these comments ask is ‘should we have strict parameters and guidelines around each discipline so that everyone knows precisely what their role is OR should we all have an understanding of each other’s work sufficient that the best person for the job is the one who will get the most out of a player regardless of discipline?’

It’s an interesting question.

The comments were of course a reference to the plethora of different specialist practitioners within our industry and the way in which they integrate - or not - on a day-to-day basis in managing players.

Recently, a member called to complain that they had not been involved in a players rehab. It turned out that the player had been passed around between a sports therapist, a sports scientist then on to a physiotherapist and finally a Strength and Conditioning Coach. Given the players career was ultimately on the line and the overall rehab process had not been successful, this had led to finger pointing and blame being bandied about amongst those involved. Some of our members jobs were also therefore on the line.

Like it or not this scenario is not uncommon and staff integration is a topic that arises more frequently than any other in general conversations.

The answer to such a scenario might just be found at our Annual Conference, which explores the roles and contribution that each discipline can make to the overall rehabilitation process. With a raft of case studies and superb line-up of speakers I am sure there will ensue a lively debate and maybe a workable solution to an ongoing issue.

Salmon Eamonn Chief Executive Officer Football Medicine & Performance Association

FROM THE EDITORS

As we come to the end of another exciting football season, we reflect on the many triumphs and challenges that we have encountered over the course of the season. In this edition, we bring you a range of articles covering a diverse set of topics, starting with an overview of common injuries experienced by professional footballers as well as avenues of management.

We also explore the use of ultrasound assessment of hamstring muscle structure, offering a valuable tool for monitoring and managing injuries in this important muscle group. As well as hamstring muscle assessment, this edition delves into the assessment of another important structure and a common site of injury in footballers, the hip and groin. We take a closer look at the latest research and practical strategies in managing and preventing these common injuries. We feel the two areas above are important to cover, especially at times of fixture congestion or towards the end of the season. This leads us to the topic of tactical periodisation and how it aims to optimise the athlete’s preparation to football matches. This is particularly key towards the end of the season and this article is the first of a two part series on this topic.

As well as injuries, this edition explores the role of sports nutrition and psychology in the process of returning players to the pitch, highlighting key strategies and considerations for effective rehabilitation. Hence, we feel this edition offers a multidisciplinary approach to the care of footballers by covering multiple domains.

We hope you enjoy the 42 nd edition of Football Medicine & Performance and as usual, we always welcome your feedback.

Dr Sean Carmody Editor, FMPA Magazine

Dr Fadi Hassan Editor, FMPA Magazine

Dr. Andrew Shafik Editor, FMPA Magazine

Sean Carmody Fadi Hassan Andrew Shafik

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Photography Alamy, FMPA, Unsplash

Cover Image Rangers’ Kemar Roofe receives medical treatment. Kemar Roofe could be set for another lengthy spell on the sidelines as the Rangers striker waits on the prognosis of a shoulder injury. 15th Janauary 2023

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

Photo: Alamy

Ian Horsley Lead Physiotherapist

Dr Jon Power Director of Sport & Exercise Medicine

Dr Dáire Rooney Doctor

Dr Andrew Butterworth Senior Lecturer Frankie Hunter Lead Sports Scientist

Dr Manroy Sahni Medical Doctor

Eleanor Trezise Medical Student

Matthew Brown Academy Sports Scientist

Callum Innes Medical Doctor

Kevin Paxton Strength & Conditioning Coach

Dr Avinash Chandran Director

Mike Brown Head of Physical Performance Jake Heath Elite Sports Specialist Podiatrist

Lisa Edwards Sports Therapist

Dr Jose Padilla MD Sports Medicine Specialist

Dr Daniela Mifsud Doctor & Physiotherapist

Dr Danyaal Khan Academy Doctor

37 The Rise of

Imaging in Elite

42 Sport-Related Concussion in High School Soccer: Females have Higher Injury Rates and Longer Return-to-Sport than Males

46 Unravelling Hip & Groin Pain

Noake

INJURIES IN PROFESSIONAL FOOTBALL - SHOULDERING THE BURDEN

FEATURE

/ DR IAN HORSLEY PHD, MCSP, MMACP, CSCS

Football is the most popular team sport worldwide. In the last global census undertaken by FIFA, it was estimated that there are over 300,000 clubs and 265 million people who participate in the sport along with more than 5 million referees. This equates to 4% of the world’s population. In this country, The Football Association represents about 37,000 clubs and millions of players . A recent FIFA study reported that in the last decade more than 13 million women have been recorded playing football at both amateur and elite levels across the globe (FIFA, Women’s Football MA’s Survey Report, 2019).

There is a saying in sport that “injury is just part of the game”. In other words, injury is seen as an inevitable consequence of participation in sport (Chalmers, 2002). Within a professional football team with a squad of 25 players, the team will endure about 50-time loss injuries each season. This equates to two injuries per player per season (Ekstrand et al., 2011).

A recent systematic review and meta- analysis of 44 studies that reported the epidemiology of injuries in male professional football concluded that the overall incidence of injuries

in professional male football players was 8.1 injuries/1000 hours of exposure, with match injury incidence being approximately 10 times higher than training injury incidence rate (Lopez-Valenciano et al., 2020). This tallies to 50-55 time loss injuries per team/season (2 injuries per player/season) which equates to approximately 14% of squad unavailable at any time.

A similar systematic review and metaanalysis carried out in Women’s football reported that the overall incidence of injuries in female football players was 6.1 injuries/1000 hr of exposure, and that match injury incidence is almost six times higher than the training injury incidence rate (Lopez-Valenciano et al., 2021).

Both papers reported that lower limb injuries were most prevalent with muscle/tendon injuries being the most common injury type. This was also confirmed in a study carried out by Kirkendall and Dvorakould (2010) who reported that the most common injured site was the lower limb (67.7%). Furthermore, they also reported that the next most injured area was upper limb (13.4%) .

Recent FIFA data shows the prevalence of upper limb injuries by playing position (Table 1) and anatomical location of upper limb injuries (Table 2).

Injuries have considerable negative physical, psychological and financial short and long-term outcomes for an individual player and their respective clubs (LopezValenciano et al., 2021). So, it is necessary to construct efficient preventive risk mitigation strategies (Roe et al., 2017) and improve our understanding of causality, effective management and rehabilitation of injuries.

In recent years, shoulder injuries have represented an increasing health problem in football players (Lungo et al., 2012). There have been a few studies which have analysed the incidence of shoulder injuries within professional (male) football. Walden et al.,( 2007) reported an 8.8% prevalence during Euro 2004, Junge et al., (2006) reported a 6.4% prevalence during the Athens Olympic Games, and Junge et al., (2004) reported a prevalence ranging from 2-13% over a four-year review of FIFA tournaments and Olympic Games.

Within the Women’s game similar figures have been returned for shoulder injuries; 5.3% (Faude et al., 2005), 2% ( Jacobsen et al., 2007), 4.7% (Tegnander et al., 2008) and 5.5% (Walden et al., 2007).

Just over a quarter of shoulder injuries (28%) sustained by professional football players are classed as severe as this results in the said players to be unavailable to train or play matches for around 28 days (Ekstrand et al., 2011). In a study carried out during the 20062008 UEFA European Championships, a total of 34 severe injuries were documented, of which two were dislocations of the shoulder (Hagglund et al., 2009). One review assessed the serious shoulder injuries sustained in professional football over a period of four competitive seasons for all English Premiership Football teams. Based on health insurance claims, this review noted that 3.3% of all claims were shoulder injuries (1335). This equates to an average of 445 serious shoulder injuries per year. The vast majority of surgical procedures were arthroscopic stabilisations (26%) and labral repairs (23%) (Pritchard et al., 2011).

With the gradual increase in shoulder injuries within football, there has been a drive to prevent shoulder injuries. Following the successful implementation of the FIFA 11+ programme which was developed to prevent lower limb injuries (Bizzini & Dvorak, 2015), FIFA developed the FIFA 11+ shoulder (FIFA 11+S) (Ejnisman et al., 2016) which targets the prevention of shoulder injuries in goalkeepers but can be applicable to outfield players also.

The program consists of three parts which takes 20-25 minutes to complete and should be carried out as part of the goalkeeper warm up as explamfied.

• Exercises to develop strength and balance of the shoulder, elbow, wrist, and finger muscles (part II)

A randomised controlled trial of the programme to assess the effectiveness of the FIFA 11+S program in reducing the incidence of upper extremity injuries among amateur soccer goalkeepers (Attar et al., 2021), reported 50% fewer upper extremity injuries among soccer goalkeepers, compared with a regular warm-up.

Return to play after shoulder injury should be founded on objective measurements (Gumina et al., 2008) and includes evaluation of the player’s health status, participation risk and extrinsic factors (Lephart, 1994).

Since the whole kinetic chain has a role in optimal function of the shoulder girdle, the distal elements and their influence on local function should be taken into consideration. It is vital, therefore, that an attempt is made to identify sub-optimal movement strategies along the length of the whole kinetic chain and focus on these in the rehabilitation process. In summarising the primary functional requirements of the kinetic chain, Boyle (2016) enquired whether the primary requirement for the shoulder girdle to function optimally is mobility or stability. It was concluded that the shoulder girdle requires alternating both stability and mobility.

• General warming-up exercises (part I)

Kinetic chain shoulder rehabilitation incorporates the dynamic link of biomechanics to produce proximal-to-distal motor-activation pattern with proprioceptive neuromuscular facilitation and closed kinetic chain exercise techniques. This method centres on movement patterns rather than isolated muscle exercises. Patterns consecutively uses the leg, trunk, and scapular muscle system to facilitate less active shoulder musculature, to gain an increase in active range of motion, and increase in force output.

Examining the kinetic chain from the ground up, we can consider the optimal requirements of the joint; namely whether the primary requirement of the joint is that of stability or mobility (See Table 3). The results are an alternating prerequisite of stability and mobility along the whole kinetic chain.

In addition to this, it is necessary to consider the “strength” requirements of the shoulder girdle such as muscle force production characteristics and whether there is a requirement for a high rate of force production, high endurance capacity or high-speed movement. Moreover, the type of muscle action (concentric, eccentric, isometric) in what part of the available joint range (inner range, middle range, outer range) is required.

Furthermore, it is necessary to understand the functional requirements of the shoulder of the player. It goes without saying that the functional requirements of the shoulders of a goalkeeper is much more complex than that of an outfield player, but one needs to consider the role of the arms (and thus shoulders) in outfield players in activities such as jumping, fending off an opponent or taking throw ins. This can be broadly broken down into what percentage of time is the arm used below the level of the shoulder, in line with the shoulder or above the shoulder. The consensus for this distribution is shown in Figure 1.

Joint Primary Requirement

1st MTP Mobility

Mid Tarsal Stability

Ankle Mobility

Knee Stability

Hip Mobility

Lumbo-Pelvic Spine Stability

Thoracic Spine Mobility

Scapula Stability

Glenohumeral Mobility

Table

Although not part of the functional requirements of players during match play, ever increasing elaborate goal celebrations may place shoulders in vulnerable positions- such as when completing a cartwheel!

Once all these characteristics have been considered, an assessment process can be carried out to identify whether these attributes are available to the player.

Further information regarding management of shoulder injuries in football can be found at TheGoalieshoulder.co.uk along with specific prevention and rehabilitation interventions.

Attar WSA, Faude O, Bizzini M, Alarifi S, Alzahrani H, Almalki RS, Banjar RG, Sanders RH. The FIFA 11+ Shoulder Injury Prevention Program Was Effective in Reducing Upper Extremity Injuries Among Soccer Goalkeepers: A Randomized Controlled Trial. Am J Sports Med. 2021 Jul;49(9):2293-2300.

Bizzini M, Dvorak J. FIFA 11+: an effective programme to prevent football injuries in various player groups worldwide-a narrative review. Br J Sports Med. 2015;49(9):577–579.

Boyle M. Functional Training for Sports (2nd edn). Human Kinetics 2016.

Chalmers DJ. Injury prevention in sport: not yet part of the game? Inj Prev. 2002 Dec;8 Suppl 4(Suppl 4):IV22-5. Ekstrand J, Hägglund M, Waldén M. Injury incidence and injury patterns in professional football: the UEFA injury study. Br J Sports Med 2011;45:553–8.

Ejnisman B, Barbosa G, Andreoli CV, de Castro Pochini A, Lobo T, Zogaib R, Cohen M, Bizzini M, Dvorak J. Shoulder injuries in soccer goalkeepers: review and development of a FIFA 11+ shoulder injury prevention program. Open Access J Sports Med. 2016 Aug 8;7:75-80.

Faude O, Junge A, Kindermann W, et al. Injuries in female soccer players: a prospective study in the German national league. Am J Sports Med 2005;33(11):1694-700.

Gumina S, Giorgio GD, Postacchini F, Postacchini R. Subacromial space in adult patients with thoracic hyperkyphosis and in healthy volunteers. La Chirurgia degli Organi di Movimento 2008;91(2):93-96

Hagglund M, Walden M, Ekstrand J. UEFA injury study: an injury audit of European championships 2006–2008. Br J Sports Med. 2009;43(7):483–484.

Jacobson I, Tegner Y. Injuries among Swedish female elite football players: a prospective population study. Scand J Med Sci Sports 2007;17(1):84-9.

Junge A, Langevoort G, Pipe A, et al. Injuries in team sport tournaments during the 2004 Olympic Games. Am J Sports Med 2006;34(4):565-76.

Junge A, Dvorak J, Graf-Baumann T, et al. Football injuries during FIFA tournaments and the Olympic Games, 1998-2001: development and implementation of an injury-reporting system. Am J Sports Med 2004;32(1 Suppl):80S-9S.

Kirkendall DT, Dvorak J. Effective injury prevention in soccer. Phys Sports Med. 2010;38(1):147–157.

Lephart SM. Re-establishing proprioception, kinesthesia, joint position sense and neuromuscular control in rehab. In: Rehabilitation Techniques in Sports Medicine, St. Louis, MO, Mosby 1994;118–37

Longo UG, Loppini M, Berton A, Martinelli N, Maffulli N, Denaro V. Shoulder injuries in soccer players. Clin Cases Miner Bone Metab. 2012;9(3):138–141.

López-Valenciano A, Raya-González J, Garcia-Gómez JA, Aparicio-Sarmiento A, Sainz de Baranda P, De Ste Croix M, Ayala F. Injury Profile in Women’s Football: A Systematic Review and Meta-Analysis. Sports Med. 2021 Mar;51(3):423-442.

López-Valenciano A, Ruiz-Pérez I, Garcia-Gómez A, Vera-Garcia FJ, De Ste Croix M, Myer GD, Ayala F. Epidemiology of injuries in professional football: a systematic review and meta-analysis. Br J Sports Med. 2020 Jun;54(12):711-718.

(Pritchard C, Mills S, Funk L, et al Incidence and management of shoulder injuries in premier league professional football players British Journal of Sports Medicine 2011;45:A15.)

Roe M, Malone S, Blake C, et al. A six-stage operational framework for individualising injury risk management in sport. Inj Epidemiol. 2017;4(1):26.

Tegnnder A, Olsen OE, Moholdt TT, et al. Injuries in Norwegian female elite soccer: a prospective one-season cohort study. Knee Surg Sports Traumatol Arthrosc 2008;16(2):194-8.

Walden M, Hagglund M, Ekstrand J. Football injuries during European Championships 2004-2005. Knee Surg Sports Traumatol Arthrosc 2007;15(9):1155-62.

Figure 1: Estimation of Functional Shoulder Position in Football

3: Primary Requirements of the Kinetic Chain (Boyle, 2016)

BRINGING WELL-BEING INTO THE PERFORMANCE PICTURE

FEATURE / SARAH MURRAY INTERVIEW BY DR ANDREW SHAFIK

This is a transcript of the FMPA Podcast episode of the same name that was released in March 2021. It has been edited for clarity and to improve readability. It was transcribed by Elle Trezise.

If you’d prefer to listen, episodes can be found on the FMPA website, Apple Podcasts, SoundCloud and Spotify.

In this podcast episode host Dr Andrew Shafik, a medical doctor working in professional football and a Senior Editor in the FMPA Education Team, speaks to Sarah Murray, a self-employed Sports Psychologist who at the time of recording was a Senior Psychologist at a Women’s Super League (WSL) club.

Andrew

I am delighted to be joined by Sarah Murray. Sarah is currently the Women’s Senior Psychologist for a WSL team (top tier).

Sarah graduated with a degree in Sports Science and then completed a PGCE in PE Teaching. After eight years as a physical education teacher, she decided to pursue her passion for the mental side of performance and completed a MSc in Sports Psychology at Brunel University, going on to gain BASES accreditation. Before going full-time in football, she ran her own consultancy working with both individual athletes and teams including England Cricket, professional golfers, England Athletics, AASE programmes, England Lacrosse, Football Referees Association and Sports Coach UK. Sarah has many years coaching and playing experience in sport, including having played national league hockey and played at regional level in cricket, tennis and football.

Thank you for joining us today, Sarah.

Sarah

Thanks very much. Nice to be here.

Andrew

Today we’re going to discuss a little bit more about your experiences today as well as sports psychology which I know will be of great interest to our listeners. So, following on from the intro, do you mind telling us a little bit about your journey to date?

Sarah

Yeah, sure. So, I guess you came up to the point where I found myself, unplanned, in full time professional football. So as a performance psychologist - we’re going back to 2013 - I was fortunate enough to have

been offered a full-time role with my current club. Which at the time was incredibly rare. There were only a couple of other full-time performance psychologists in football anywhere in the country.

It was the first time that the club had a performance psychologist on that sort of level. I think they’d had some workshops here and there, but they were really keen that if they were going to look into the mental side of the game and support players with that, they were going to do it properly with somebody full-time and a full programme. So, I think, to be honest, it probably took the first four or five years to really work out where does this sit within the club? Where will it add the most value? Who will I be working most closely alongside? Between myself and my colleagues in the sports science and medical department, and my colleagues in the coaching and Academy departments, we sort of figured out where it adds value and where the role is best suited. Then I was fortunate enough to be able to build the department and employ other performance psychologists within the club to support the work that we did. As time passed, it was genuinely the most privileged experience that I’ve had to be able to build that department. Particularly within the Academy. So, under-23s and down is where the focus of the performance psychology was. Alongside a little bit of lecturing, just to keep my hand in with the latest applied research, it’s been a great journey so far.

Andrew

That’s great. Really, really interesting to hear about your background there, Sarah. Delving a little bit more into the performance psychology side of things, what is it about the narrative of well-being and elite performance that is important? What is it? What isn’t it?

What’s your take on it?

Sarah

This is something that I’ve spoken passionately about and sort of worked really hard with over the last few years, particularly since being in football. There’s a historic narrative of well-being or performance that we’re shifting away from, and we’re shifting away from very quickly both within football but culturally within performance sport and actually within society more broadly, I’d say.

After years of almost battling for acknowledgement of how well-being supports performance, I was really keen to shift the narrative and actually have well-being as a key part of performance. Certainly, if we have well-being without performance, then we’re not a high performing elite football environment because we have to have the performance piece. But equally if we have performance and we are focused heavily on performance without a well-being underpinning, then we end up in the historical cases of burnout and - worst case scenariosome of the historical mental health problems that athletes have had when well-being hasn’t been a part of the conversation, or hasn’t been a narrative. So, I think this idea of bringing well-being into the performance environment deliberately as a key part of supporting athletes to perform is absolutely invaluable.

Andrew

That’s interesting. Obviously, there’s been lots of media attention. We’ve seen the recent article from Sky Sports about psychology in sport and if it’s a missed opportunity in the English game. Why do you think now is really the time for performance psychology in sport as well as football?

Dr Andrew Shafik

Sarah Murray

Sarah

I think everything comes around in cycles. Performance psychology has been around for decades but there’s no question that potentially last to the table in terms of really utilising it as a sport, you could argue has been football. But what I love about the game and about football is that once they do get hold of something they genuinely will go all in and run with it and many football clubs are now running some fantastic performance side programmes and getting some really great professionals in to work into this space. But I think the fluffy stuff, as I’ve heard it called, the fluffy stuff – “do you wear a white coat and then players come in and cry on your sofa?” And a lot of the cultural assumptions around the word “psychologist” even… it takes a long time to break these down and then for a performance psychologist to work into a sports space and particularly football which is where I’ve spent the last eight years, as being normal, as being something whereby an athlete will have access to great physios, doctors, sport scientists, nutritionists, and actually to have a performance psychologist as part of that MDT, is just the norm. At my current club certainly. I think now more broadly in football we’re seeing less and less news articles - which is really pleasing to see - whereby it becomes an article on BBC Sport or perhaps Sky Sports that X footballer, who’s a professional footballer, seeks a psychologist. Whereas if that footballer is struggling with his change of pace, his speed, whatever, it wouldn’t be a story that he went to see a sport scientist. Because actually, there’s no difference. So, I think it’s coming.

As we record this today, we’re still in a lockdown and we have been for the best part of a year, and there’s no question that it’s accelerated the conversation of mental health and wellbeing just more broadly in society and self-care, and a realisation of how this can then support performance. So, mental recovery and physical recovery for the players that I work with are equally valued in my environment and measured as something that will then support the performance on the Sunday.

Andrew

That’s interesting and I think it’s definitely an integral part of the whole performance picture. I recently listened myself to the High Performance Podcast and in an episode with Tyrone Mings, he was explaining some of the barriers before COVID to seeking psychology and how he now finds it is an integral piece to his overall performance picture. So, it’s partly due to that breaking down of barriers which is great to hear. What are some of the challenges that you found when tackling down some of those barriers, especially now? You mentioned COVID but are other things associated as well?

Sarah

Yeah, certainly. I mean, if I take myself back to

when I when I first came into a full-time role as a performance psychologist, what I expected and my reality were quite different. So, what I expected to walk into was an environment that was high performance, professional football, male dominated. So as a female, as a psychologist, you know, when we have the -ologist on the end of our job title, it can be quite unhelpful, I have found. So I actually expected that there might be a lot of blocks and barriers to the work that I was doing and to the way I wanted to support athletes and staff alike. The reality was that there wasn’t. I’m very fortunate that actually I work in an environment that is incredibly open to supporting not just the players within the club, but the staff as well. So those blocks and barriers I thought I might face, I haven’t. That said, I can only speak for my reality, and that’s been my reality. I have colleagues that have not been so fortunate and have had far greater struggles with integrating performance psychology into a performance environment, and really breaking down that idea of it being for the weak and breaking down that idea of it being for simply issues-based problems.

I think, on a personal level, coming from a performance background and playing to a fairly good level myself in hockey, and always being performance focused has helped me in terms of my understanding of the performance culture, and actually working with somebody whether they are in a fantastic space, so they’re mentally in a great space and there’s always work to be done to make that better. Equally, if somebody is struggling and they’re not in a great space, is there work to be done to actually bring them

into a better space to be able to perform on a Saturday or on a Sunday? So, I guess, coming in from the angle that I have done, the blocks and barriers weren’t necessarily there but culturally to seek help, culturally to go and see a psychologist or a psychiatrist in the UK, is still not something that has happened or been talked about for decades. Whereas if we look at America and other countries where it’s the norm, everybody has a psychiatrist, everyone has a psychologist. I appreciate that is a sweeping generalisation. However, it’s certainly part of their culture. For us, it’s the open conversation around mental health that’s happening at the moment and actually the way in which, from an athletic point of view, athletes can be supported by looking after [their mental health] is helping us to break down those barriers, and to make it part of something that can support the human - the man behind the shirt or the girl behind the shirt - which ultimately, then when they step onto a pitch, or a court, is going to support them to perform.

Andrew

That’s brilliant. You’ve mentioned your wealth of experience across a variety of sports there which kind of leads onto the next question: how does psychology look when it’s integrated into a high performance environment?

Sarah

Oh my goodness. I think that’s something else that as a profession we’ve probably struggled with because it can look so different, because it is very much dependent on the person, on the psychologist, on their philosophy, their way of working, as to how it looks in the environment. So how it can look is… traditionally it was based in sport science and medicine. Certainly when I joined my current club, I was put into the sports science and medicine department but over the years, just found myself immersing myself in the world of the coaches and spending my time in an amongst the coaching staff to then become actually a member of that department, although working across. So, when sports psychology is integrated into any kind of sport, I think it’s dependent on, you know, what are the needs of that organisation, or that particular team, or

Bringing well-being into the performance environment deliberately as a key part of supporting athletes to perform is absolutely invaluable

that individual? What is it that they’re wanting to get from it? I think it’s a case of making sure that the needs of the organisation are met by the sport psychologist because certainly if there’s a disconnect or there’s not a fit between the philosophies and the values of the sports psychologist coming in and what they see as their role, if it doesn’t connect with what the organisation wants, then same with any profession, it’s not going to be as effective. So, broadly speaking, it’s looking at working across the MDT, supporting staff, supporting coaches.

Certainly for me, one of the other shifts over the last eight years is that I’m far more staff-facing now than I probably would have been ten years ago when I was a little more traditional in terms of working with the athlete, working with the young footballer one-to-one and supporting him and that was it. Working at a systems and organisational level now as a performance psychologist is far more common. If we think about the long-term impact of having performance psychology, mental health and well-being embedded into elite environments, then that’s the way forward, to do it from a systems level, to work with the coaches, to support the sport scientists. You’ve had some great guys on this podcast already that I’ve worked closely with within my role at my current club even and yeah, so, definitely holistic.

Andrew

That’s great. You’ve kind of mentioned towards the end there that it’s been more staff facing. So, looking at an athlete or a coach and trying to get buy in, how’ve you found that element? Any skills or tips in regard to getting buy in? What do you define as the performance benefits to them?

Sarah

I mean, if I were to anecdotally think about the amount of conversations that I would overhear and many of your listeners would overhear in their sport environment that are coach to coach, player to coach, player to player. So many of the conversations are based in the mentality, the mindset of the player. So many of them. So actually, there’s massive value placed on the mindset and the mental side of the game.

However, because it’s psychology, because there’s an -ologist… it’s not as data driven as sport science, so it’s harder to say, “this psychologist can come in and this data here will be improved in six months’ time” and it’s really easy for us all to see and understand. So, there’s been this fear of “we really value it but we’re not quite sure how it works or what to do with it. So, we’re not too sure if we want to bring it in.” Although, as I said, all the conversations are driven towards the mentality side of the game. So, to get buy in, it’s no more or less than supporting coaches to get the best from themselves and to get the best from the players that are around them.

The more we know and understand about our athletes, and understand their context, their journey, and why they do what they do, why do they behave as they do on a match day? Why does that member of staff perform so well in this environment and do this but then maybe struggle here? The more we understand about people, ultimately the people behind the badge, the more we are going to find those connections and actually be able to support them to get the best out of themselves and understand themselves when they’re asked to step up on a Sunday or a Saturday on a match day, in a highpressure situation and perform and do their role.

So really, I guess it’s just about formulating. Formulating on players, formulating on staff. How do we get the best out of them? What are their protective factors in life? What’s their context? What’s their journey? How do they feel and act and sound in our environment when they’re at their best and how do we help them to do that?

Andrew

That’s really interesting. I think it’s a really strong message. A lot of conversations, even a lot of the podcasts around sport are associated with the mindset of performance. It is a nonnegotiable having that psychology element when you’re a professional who’s experienced in that environment.

Just to finish off, you’ve worked across age groups, across individual and team sports, the

men’s and women’s game as well as across plenty of sports generally. What are the things that you’ve found most useful to transfer across to football? What are the similarities and some of the differences? I know that’s quite a difficult question!

Sarah

I’ll do my best! I think ultimately, whilst there are contextual differences in terms of what happens for an athlete and their experience, whether they are a real tennis player or they’re a lacrosse player or a golfer, their environment might be slightly different. But ultimately, many of the skills needed to be able to be at your best and understand yourself in a performance environment actually remain quite similar across many of the sports and some of the transferable things I’ve taken from other sports into football would be understanding the culture and actually understanding what’s going on for the people in that world. So, for me to come in and think that I know everything about football as a professional… absolutely not, you know. I’ve learned along the way I don’t need to have played elite level football to be able to walk into football and make some impact. So, it’s a two-way learning process. I think one of the most influential experiences I had early on would have been as a young practitioner, working across lots and lots of sports. So, whilst I was really lucky, and I worked with the England Women’s Cricket pathway and GB Real Tennis and then some elite golfers, I also worked with a lot of grassroots athletes.

If I was to say the absolute top transferable skill, it would be that ultimately, I work with human beings. So, whether it’s our conversation today, whether it’s an under-9 tennis player playing for their local club, or whether it’s a 32-year-old professional male footballer that’s in the premiership, the value of working with the human in front of you - as a human first, an athlete second - doesn’t change for me. So, that’s transferable across all contexts across any performance environment, be it sport, business, cricket or football.

Andrew

That’s brilliant, Sarah. Thank you very much for joining us today. I think that’s been a really good insight into performance psychology within the men’s game as well as across sports. I think it will be applicable to those working in academy football, men’s football, women’s football as well as other sports as well. Listeners, I’ll put up the links to the papers mentioned and if you enjoyed today, please subscribe to the FMPA on our Spotify and SoundCloud accounts where you can reach all of our podcasts. Alternatively, our podcasts are also available for free in the podcast section of the FMPA website. Thanks again, Sarah.

The skills needed to be able to be at your best and understand yourself in a performance environment actually remain quite similar across many of the sports

ULTRASOUND ASSESSMENT OF HAMSTRING MUSCLE ARCHITECTURE – THE LINK TO INJURY

Introduction

In field-based sports, if a player sustains an injury, medical staff are often asked by the team management “when can he/ she play again?” (Ekstrand et al., 2016). Hamstring Strain Injuries (HSI) are one of the most common injury in sports (Ekstrand et al., 2016), with the majority of injuries occurring in the Bicep Femoris long head muscle (Green et al., 2020). They have a high injury burden for fieldbased sports athletes, particularly soccer, accounting for 37% off all muscular injuries in that sport, which is the world’s most popular sport (Askling et al., 2013; van der Horst et al., 2015). Despite considerable research to identify athletes vulnerable to HSI, a mean increase in the rate of HSI (4%) is observed (Ekstrand et al., 2016; Ekstrand et al., 2022). Indeed the prevalence of hamstring strain re-injury ranges from 14% - 34% within the same

competitive season (Green et al., 2020). Researchers, medical staff, and the athletes themselves have little control over intrinsic factors often linked to developing an HSI such as increasing age, ethnicity, and previous HSI. However, researchers and medical staff are aware of some modifiable risk factors, such as understanding the link and importance of the architectural characteristics of skeletal muscle and how it impacts HSI.

Muscle Architecture

Muscle architecture refers to the geometric distribution of fascicles within a muscle. Muscle architecture governs the mechanical function of a muscle, influencing its maximal force output and its contraction velocity (Lieber and Ward, 2011). The angle of trajectory of a muscle fascicle between the

superficial aponeurosis and its insertion into the mid aponeurosis is referred to as its pennation angle (Figure 1). Large pennation angles associate with shorter muscle fascicles, which reduces the contractile velocity and excursion range of the muscle. In contrast, small pennation angles associate with longer muscle fascicles, which decreases the physiological cross-sectional area and maximal force output of the muscle. Muscle excursion range is proportional to muscle fascicle length (Lieber and Ward, 2011) (Figure 1). Indeed, when compared to short muscle fascicles, long muscle fascicles contain more sarcomeres in series (Timmins et al., 2016b). During fast eccentric activity (i.e., the typical mechanism associated with hamstring strain injuries), the muscle tendon unit undergoes active lengthening (Blazevich and Sharp, 2006). During this type

Lecturer, School of Medicine, University College Dublin, Ireland

of contraction, long muscle fascicles, compared to short muscle fascicles, will exhibit less strain per sarcomere in series (Timmins et al., 2016a).

Muscle Architecture and Hamstring Injury

While limited evidence exists to characterise the effect of hamstring muscle architectural characteristics on strain injury, a single prospective study of 152 elite-level Australian soccer players has demonstrated that those athletes who possessed shorter Bicep Femoris long head fascicle lengths (<10.56cm) were four times more likely to sustain a future HSI than those with longer fascicles (Timmins et al., 2016a). Shorter muscle fascicles contain less sarcomeres in series, which will result in a reduced maximal shortening velocity, which could increase the risk of re-injury (Timmins et al., 2016a). Indeed, previous research identified that the level of probability of Bicep Femoris long head muscle injury was reduced by 21% for every 1cm increase in fascicle length (Timmins et al., 2016a). Therefore, the ability to accurately quantify the architectural characteristics of the hamstring muscles may assist clinicians in the management of athletes with acute or recurrent hamstring strain injuries.

Measuring Muscle Architecture

Hamstring Architecture Acquisition Brightness mode (B-mode) ultrasound

is the most commonly used medical imaging modality to assess the architectural characteristics of skeletal muscle. It is non-invasive and well tolerated by the athletes. However, the acquisition of accurate high quality ultrasound images of the architectural characteristics of the hamstring muscles is challenging and operator dependent (Balius et al., 2019). The majority of published research using B-mode ultrasound to measure the architectural characteristics of the hamstring muscles has utilised a field of view that is typically shorter that the fascicle being measured (Timmins et al., 2016a; Duhig et al., 2019). . In these cases, fascicle length is estimated with various linear approximations (trigonometric linear method) using the measured muscle thickness and pennation angled values. However, these methods fail to consider the variability associated with fascicular curvature and as such are prone to error, often estimating at least 50% of the entire fascicle (Figure 2A). Indeed, extended field of view ultrasound technique has been used to permit full fascicle visibility in the past. Extended field of view ultrasound is a dynamic technique that requires the operator to shift the ultrasound probe along the muscle to generate a composite ultrasound image from a series of images. However, the Bicep Femoris long head muscle exhibits a heterogenous muscle architecture with fascicles orientating themselves in a nonlinear path and thus, any misalignment of

the ultrasound beam from the plan of the fascicles will lead to fascicle length errors (Klimstra et al., 2007; Bolsterlee et al., 2016) (Figure 2B). Extended field of view is a technically challenging ultrasound technique, often leading to fascicle crossover (meaning the fascicle cannot be measured accurately) and is not supported on some ultrasound imaging systems. Recently, wide field of view ultrasound was utilized to quantity the hamstring muscles architectural characteristics, illustrating excellent repeatability for measuring fascicle length (Cronin et al., 2022). Wide field of view is a reliable ultrasound technique to acquire hamstring muscle architecture permitting full fascicle visibility. Wide field of view ultrasound utilizes a field of view (>92mm) that is typically longer than the fascicles within the bicep femoris long head muscle (Figure 2C).

Hamstring Architecture Analysis

Once ultrasound images of the hamstring muscles are acquired, it is necessary to measure the architectural characteristics (e.g. fascicle length). Acquired static sonograms of the hamstring muscle architecture are often manually digitised which requires the operator to manually select points along a fascicle to determine fascicle length. These manual skeletal muscle image tracking algorithms quantify fascicle length in a linear fashion, and fail to account for fascicle curvature and as such are prone to error (Pimenta et al., 2018). More recently, automated

Figure 1: A schematic ultrasound image of the Bicep Femoris long head muscle.

tracking algorithms have been developed primarily to quantify skeletal muscle for studies using a large number of ultrasound images (Zhao and Zhang, 2011; Farris and Lichtwark, 2016; Drazan et al., 2019). These tracking algorithms are developed to account for fascicle curvature which improves fascicle length measurement accuracy however they still estimate fascicle length as the acquired sonograms are captured with ultrasound field of views typically smaller that the fascicle length. Furthermore, one key limitation of these automated tracking algorithms is, frequently the same fascicle is not tracked overtime (Zhao and Zhang, 2011). This is often due to the variation in the “intensity of the fascicle” from the resultant sonogram (Zhao and Zhang, 2011), in other words the inability of the automated tracking device to analyse the same fascicle in a different sonogram due to software difficulties in identifying the fascicle. This further emphasises the need for high quality sonograms to ensure that these automated tracking algorithms work efficiently by capturing the same fascicle overtime, and effectively reducing fascicle length measurement error. Recently, a group of researchers in University College Dublin have developed a semi-automated tracing software tool that exhibited excellent precision when measuring the architectural characteristics of the hamstring muscles (Cronin et al.,

2021). The semi - automated tracing tool has been demonstrated for static ultrasound images which permits full fascicle visibility within the ultrasound image. The semi – automated tracing software tool could be of substantial interest to clinicians interested in hamstring strain injuries who may want to precisely measure fascicle lengths following injury and in response to exercise – based interventions.

Ultrasound screening to reduce hamstring strains?

A limitation of many prospective studies is that associations with injury risk are made from measurements taken at a single time point (e.g., pre – season) (Opar et al., 2022), whereas hamstring strain injuries can occur at any time period when the athlete is training or in competitive action (Green et al., 2020). However, more regular assessment at multiple time points throughout the course of an athletes competitive season of the hamstring muscle architecture provides a better reflection of the association of fascicle length with hamstring injury, because Bicep Femoris fascicle lengths change over the course of a season (Timmins et al., 2017). Further, as previously mentioned, the ability to trend hamstring architectural characteristics is dependent on the accuracy and

precision of the ultrasound measurement technique (ultrasound image acquisition and image analysis software). A potential approach for overcoming the aforementioned ultrasound imaging limitations is through employing a transducer with a wide field of view that captures the entire fascicle (Cronin et al., 2022), avoiding the need to estimate fascicle length and precisely measuring fascicle length on a software that accounts for fascicle curvature (Cronin et al., 2021).

Conclusion:

• Hamstring muscle architecture is an extrinsic risk factor for injury.

• To trend hamstring architecture accurately in athletes is dependent on the ultrasound technique and measuring software tool used.

• Wide field of view ultrasound is a reliable ultrasound technique to acquire high quality ultrasound images of the hamstring muscle architecture.

• The aforementioned semi – automated tracing tool precisely measures the hamstring muscle architecture.

Acknowledgements:

Professor Eamonn Delahunt, Dr Shane Foley, Dr Sean Cournane, Fearghal Kerin.

Figure 2: Longitudinal ultrasound images of the Bicep Femoris long head muscle, A: Limited field of view (Timmins et al., 2016a), B: Extended Field Of View (Franchi et al., 2020), C: Wide field of view (Cronin et al., 2022).

Askling, C.M., Koulouris, G., Saartok, T., Werner, S., and Best, T.M. (2013). Total proximal hamstring ruptures: clinical and MRI aspects including guidelines for postoperative rehabilitation. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA 21(3), 515.

Balius, R., Pedret, C., Iriarte, I., Sáiz, R., and Cerezal, L. (2019). Sonographic landmarks in hamstring muscles. Skeletal Radiology, 1-9. doi: 10.1007/s00256-019-03208-x.

Blazevich, A.J., and Sharp, N.C.C. (2006). Understanding Muscle Architectural Adaptation: Macro- and Micro-Level Research. Cells Tissues Organs 181(1), 1-10. doi: 10.1159/000089964.

Bolsterlee, B., Gandevia, S.C., and Herbert, R.D. (2016). Effect of Transducer Orientation on Errors in Ultrasound Image-Based Measurements of Human Medial Gastrocnemius Muscle Fascicle Length and Pennation. PLoS ONE 11(6), e0157273-e0157273. doi: 10.1371/journal.pone.0157273.

Cronin, K., Delahunt, E., Foley, S., De Vito, G., McCarthy, C., and Cournane, S. (2021). Semi-automated Tracing of Hamstring Muscle Architecture for B-mode Ultrasound Images. International Journal of Sports Medicine.

Cronin, K., Foley, S., Cournane, S., De Vito, G., and Delahunt, E. (2022). Hamstring muscle architecture assessed sonographically using wide field of view: A reliability study. PloS one 17(11). doi: 10.1371/journal.pone.0277400.

Drazan, J.F., Hullfish, T.J., and Baxter, J.R. (2019). An automatic fascicle tracking algorithm quantifying gastrocnemius architecture during maximal effort contractions. PeerJ 7, e7120-e7120. doi: 10.7717/peerj.7120.

Duhig, S.J., Bourne, M.N., Buhmann, R.L., Williams, M.D., Minett, G.M., Roberts, L.A., et al. (2019). “Effect of concentric and eccentric hamstring training on sprint recovery, strength and muscle architecture in inexperienced athletes”. (OXFORD: Elsevier Ltd).

Ekstrand, J., Waldén, M., Hägglund, M., Medicinska, f., Institutionen för medicin och, h., Linköpings, u., et al. (2016). Hamstring injuries have increased by 4% annually in men’s professional football, since 2001: A 13-year longitudinal analysis of the UEFA Elite Club injury study. British Journal of Sports Medicine 50(12), 731-737. doi: 10.1136/bjsports-2015-095359.

Ekstrand, J., Bengtsson, H., Waldén, M., Davison, M., Khan, M.K and Hagglund, M. Hamstring injury rates have increased during recent seasons and now constitute 24% of all injuries in men’s professional football: the UEFA Elite Club Injury Study from 2001/02 to 2021/22 British Journal of Sports Medicine Published Online First: 06 December 2022. doi: 10.1136/bjsports-2021-105407

Farris, D.J., and Lichtwark, G.A. (2016). UltraTrack: Software for semi-automated tracking of muscle fascicles in sequences of B-mode ultrasound images. Computer Methods and Programs in Biomedicine 128, 111-118. doi: 10.1016/j.cmpb.2016.02.016.

Franchi, M.V., Fitze, D.P., Raiteri, B.J., Hahn, D., and SpÖRri, J. (2020). Ultrasound-derived Biceps Femoris Long Head Fascicle Length: Extrapolation Pitfalls. Medicine & Science in Sports & Exercise 52(1), 233-243. doi: 10.1249/MSS.0000000000002123.

Green, B., Bourne, M.N., van Dyk, N., and Pizzari, T. (2020). Recalibrating the risk of hamstring strain injury (HSI) - A 2020 systematic review and meta-analysis of risk factors for index and recurrent HSI in sport. British Journal of Sports Medicine, bjsports-2019-100983. doi: 10.1136/bjsports-2019-100983.

Klimstra, M., Dowling, J., Durkin, J.L., and MacDonald, M. (2007). The effect of ultrasound probe orientation on muscle architecture measurement. Journal of Electromyography and Kinesiology 17(4), 504-514.

Lieber, R.L., and Ward, S.R. (2011). Skeletal muscle design to meet functional demands. Philosophical Transactions: Biological Sciences 366(1570), 1466-1476. doi: 10.1098/rstb.2010.0316.

Opar, D.A., Ruddy, J.D., Williams, M.D., Maniar, N., Hickey, J.T., Bourne, M.N., et al. (2022). Screening Hamstring Injury Risk Factors Multiple Times in a Season Does Not Improve the Identification of Future Injury Risk. Medicine and science in sports and exercise 54(2), 321-329. doi: 10.1249/MSS.0000000000002782.

Pimenta, R., Blazevich, A.J., and Freitas, S.R. (2018). Biceps Femoris Long-Head Architecture Assessed Using Different Sonographic Techniques. Med Sci Sports Exerc 50(12), 2584-2594. doi: 10.1249/MSS.0000000000001731.

Timmins, R.G., Bourne, M.N., Hickey, J.T., Maniar, N., Tofari, P.J., Williams, M.D., et al. (2017). Effect of Prior Injury on Changes to Biceps Femoris Architecture across an Australian Football League Season. Medicine and science in sports and exercise 49(10), 2102-2109. doi: 10.1249/MSS.0000000000001333.

Timmins, R.G., Bourne, M.N., Shield, A.J., Williams, M.D., Lorenzen, C., and Opar, D.A. (2016a). Short biceps femoris fascicles and eccentric knee flexor weakness increase the risk of hamstring injury in elite football (soccer): a prospective cohort study. British Journal of Sports Medicine 50(24), 1524-1535. doi: 10.1136/bjsports-2015-095362.

Timmins, R.G., Shield, A.J., Williams, M.D., Lorenzen, C., and Opar, D.A. (2016b). Architectural adaptations of muscle to training and injury: a narrative review outlining the contributions by fascicle length, pennation angle and muscle thickness. British Journal of Sports Medicine 50(23), 1467-1472. doi: 10.1136/bjsports-2015-094881.

van der Horst, N., Smits, D.-W., Petersen, J., Goedhart, E.A., and Backx, F.J.G. (2015). The Preventive Effect of the Nordic Hamstring Exercise on Hamstring Injuries in Amateur Soccer Players : A Randomized Controlled Trial. American Journal of Sports Medicine 43(6), 1316-1323. doi: 10.1177/0363546515574057.

Zhao, H., and Zhang, L.-Q. (2011). Automatic tracking of muscle fascicles in ultrasound images using localized radon transform. IEEE Transactions on Biomedical Engineering 58(7), 2094-2101. doi: 10.1109/TBME.2011.2144593.

TACTICAL PERIODISATION IN FOOTBALL PART 1

Introduction

Football is characterised by the chaotic nature of the game. It is up to the trainer and his or her staff to prepare players physically, technically, tactically, and mentally. While traditional periodisation models often focus almost exclusively on the physical aspect, the concept is applied in a well-considered way in so-called tactical periodisation.

The game model of the team determines the content of training, and one does not train the components separately, rather they are integrated, like they occur during a match. In short, it is a different view of the same thing! The purpose of this article is to explore the role tactical periodisation in developing professional footballers.

From tactics to physical

In recent years we have seen a shift in the approach to football training and periodisation. (1) In an attempt to simplify the complexity of the sport, many traditional periodisation models emphasised physical attributes. However, to do justice to the identity of football, as well as to make an optimal transfer to the game, it is impossible

to train the different dimensions separately. Maximising performance is the result of multiple physical, technical, tactical, and mental skills. Tactical periodisation challenges the simplified thinking about football, which tends to limit itself to training one aspect at a time. (2,3) The concept of block periodisation, based on the idea that a large part of the training process is aimed at a minimum number of skills, has given way to this alternative approach to training and periodisation.

As the name suggests, the team’s style of play is at the heart of the entire training process. This game model is a collective term for everything that has been agreed in a team about the way they want to play, i.e., how it pressures the opponent, how the team builds up in-possession, what formation they play and so on. As a result, it gives more order and predictability to the unpredictable nature of football so the team can ultimately try to influence the result of the game. The concept of periodisation is applied in a well-considered way and refers to the tactical principles that are trained throughout the season. Driven by tactical

principles, as much training as possible should be completed in the holistic core where all dimensions overlap (see Figure 1). The game model (or style of play) acts as the overlapping dimension in which the other dimensions exist. This perspective contradicts with the common view in which the four dimensions are considered separately and with equal priority.

Method and principles

The main principle of the model is known as specificity. This relates to the extent that what you train corresponds to the match situation. The different dimensions (tactical, technical, physical, and mental) are not trained separately through isolated exercises, but together. Ideally, each exercise relates to at least one (but usually all four) moments of the game (see below), the appropriate space, game-like intensity, and decision making:

1) offensive organisation;

2) defensive organisation;

3) transition from defence to attack;

4) transition from attack to defence. (1)

Players are repeatedly exposed to football

Head of Sport Science and Strength & Conditioning FC Utrecht

Photos: FC Utrecht

situations where the physical dimension is related to one (or multiple) tactical principles of the team. Guided by these principles, they are challenged to execute technical skills while making the right choices. For example, defending zonally, where players are responsible for a specific part of the field instead of an opponent, forces them to think about their position in relation to fellow players and opponents. Another example would be compulsory folding back (or recovery runs) and closing in from behind over a specific line of restraint during games. This will not only lead to retaining compactness or holding defensive shape. Players are implicitly forced to do more high-intensity running (all distance covered above a speed of 20 km/h). Thus, rather than training individual attributes, they are trained in an integrated way, as in the game. This does not necessarily mean that only 11-a-side is played. There are times when the game is deliberately simplified, so that players better understand how to handle various game situations. Examples of such adjustments might include changing the number of players, the size and/or shape of the field of play, the work/rest ratio, the rules of the game, etc. However, it is important that this is done without losing the chaotic nature and complexity of the game. Otherwise, we would train in a way that has no connection to the reality of the game.

Besides the principle of specificity, the model has 3 sub-principles that are used to make this possible: (2,3)

1) Making the game model trainable

This is done by creating situations that make specific principles appear more often. These principles are tactical guidelines that apply in almost all situations. For example, a principle of play in offense could be that, for a striker to be available, a coach might instruct him to move to the side where the ball is. In this way, players can experience situations several times, find solutions and learn by repetition. This can be done, for example, by devising an exercise in which the attacking team is confronted with a situation in which there is a good chance of them losing the ball and they are forced into a defensive changeover. After a short period of playing on, the organisation of the exercise is restored, and the same situation occurs again. By changing the shape of the playing field, players are implicitly forced into certain actions.

2) Systematically repeating game principles

This follows a wave-like motion. The nonlinear progression can take place during the season both in the short term, from match to match, and in the long term. At the start of the season, the priority is on the fundamentals that are an integral part

of the game model. Later in the season, usually after preparation, this shifts to more complex and positional principles that can vary from match to match. There are weekly or even daily variations while the basic principles return systematically in the training programme. For example, a basic principle in defending is that players are not (wo)man-oriented. No man marking is played, but players coach their teammates to “take over” opponents when they enter their zone.

3)

Stable and recurring weekly schedule

The same distribution of physical load is maintained in relation to match days (MD: match day). The tactical objectives of each training session may vary according to the specific needs of the team, but the physical component trained on a particular day in relation to the match day (e.g. MD+1, MD-4, etc.) remains the same.

From macro to micro

Football consists of a succession of complex situations. It is characterised by highintensity actions of which the duration and intervals are unpredictable. Players need to possess a wide range of physical, tactical, and technical skills, combined with fast information processing to make the right choices under pressure. Because a football season has a long competitive period stretching over several months, with one or more matches scheduled each week, there is no such thing as peak performance. To achieve success, you need to be able to perform at a consistent level. It is therefore very important to ensure that players receive the right physical load and tactical knowledge every week, while ensuring adequate recovery and regeneration. According to the founding fathers of tactical periodisation, adaptation only occurs when training is carried out at a constant volume and high intensity every week. (1) Maximum concentration and intensity are also required

during recovery training. Players must still perform each exercise similar to how they would do it in the game. However, the complexity and duration of each exercise will be shorter and maximum recovery between repetitions is generally aimed for. Nonetheless, to stimulate players both physically and mentally, it can sometimes happen that they are not given the time to fully recover. For example, during the preseason, training is regularly carried out after a match under fatigued conditions.

The weekly dynamics of the training content remain stable in terms of the type of load, volume, intensity, and complexity. (1,2,3) Due to this cyclical nature, each training week shows only subtle tactical differences, while the physical objectives are stabilised. Table 1 shows an overview of a typical training week with one game. To avoid overtraining, recovery during the week takes place by varying the dominant pattern of muscle contraction (strength, endurance, or speed). As a result, no consecutive days have the same objective to ensure the cumulative effect of fatigue is limited. (1,3) Therefore, the complex game is broken down into daily objectives to maintain an optimal performance level. The distribution of the different variables that determine the training content, also known as Key Performance Indicators (KPIs), is always organised in relation to both the previous and upcoming match. When planning the week, the complexity of the training is therefore also considered. Especially the mental load plays an important role here. Not only the body, but the brain needs space and time to recover too. Processing information quickly and making choices under time pressure results in cognitive overload. For example, football is generally experienced as more intensive than isolated running, because high-intensity actions such as dribbling, duelling, shooting and tackling follow each other in quick succession. During

Figure 1: The traditional way of periodisation versus tactical periodisation.

the week, a training session (or match) with a lot of variation and information to process will rarely be followed by another training session with complex exercises. After a match or day off, main principles are trained that are an integral part of the game model (= low complexity). Towards the next match more focus is placed on tactical and positional details, taking into account the strategy of the upcoming opponent. The complexity will therefore increase. This does not mean that isolated forms of training are not used at all. For example, players with less physical load during the week are compensated two days before the match (MD-2) by means of isolated running drills. Furthermore, these are also used for substitutes immediately after a match (MD) if no group training or (practice) match is scheduled the following day (MD+1). Although these are tailored to the conditioning status of each player, they have a lower specificity due to the predictable nature of the exercise. While this approach may differ from what’s been described above, this shows that, on occasion we might need to be flexible in our approach depending on the context. Thinking in terms of opportunities and possibilities to offer each player an optimal training week might deserve more attention in the future. Think for example of a training immediately after the game or a different weekly schedule for substitutes.

The art and science of coaching

There is no one-size-fits-all solution for an optimal training week. Every player has his or her own way of playing at a similar position, which results in a different load. In addition, no two players react in the same way to a certain imposed load because each individual has a different load capacity. For example, a player in his thirties may need more time to recover while the same may

be true for a youth player who has only recently been added to the squad and may be exposed to cognitive and physical overload.

Finding the right balance within a group of players with different backgrounds and histories (e.g., injury history, number of years first team experience, etc.) requires an individual approach within the team periodisation. Each player is assigned to one of three load capacity groups (low, medium and high) based on both objective (e.g., scores on test programs and/or particulars from sports medical examinations) and subjective criteria (e.g., mental overload for a player who comes from youth training or abroad).

Furthermore, the match schedule in modern football is such that players often have to play multiple matches in a short period of time, with minimal recovery¬ periods in between. Due to mechanical, metabolic, and cognitive demands the resulting fatigue persists into the following days. The cause is usually

attributed to both central and peripheral factors. (4) After heavy exercise, the ability of the central nervous system to activate or control muscles is reduced. Also, muscle fibre recruitment will be reduced due to disturbances in the contractile function of muscles. Recent research has shown that these reduced functions persist up to 72 hours post-match. The same applies to subjective indicators of fatigue. Both the feeling of fatigue and the psychological lack of motivation to train persist until 72 hours afterwards (see Table 1). The divergent recovery between the perception of fatigue and objective measurements of neuromuscular function highlights the multifactorial nature of fatigue.

To design individualised training programmes, total distance (see box) is probably the most widely used load indicator in professional football. However, it does not appear to be sensitive enough and, to date, has not been associated with fatigue-related markers (4). Hader and colleagues concluded in a systematic review that the distance ran at high speed (> 19.8 km/h) is the only variable that correlates with markers of muscle damage and peak power output from muscle fibres. This Very-High Intensity Distance (VHID) could explain up to 50% of the creatine kinase (CK) concentration and neuromuscular (peak power output) responses. In practical terms, for every 100 metres of VHID, the intracellular CK concentration in muscle fibres increases by 30%, whereas the peak power output during a counter movement jump (CMJ) decreases by 0.5% up to 24 hours postmatch. Other significant relationships between external load and fatigue-related variables remain to be determined (5). Empirical evidence shows that an increase in the number of accelerations and

Figure 2: Perceptual responses measured before, after, and 24, 48, and 72 hours post-match (4).

Table 1: Weekly structure of the micro cycle decelerations causes an increased score on muscle soreness and consequently a decreased sense of recovery. It is possible that structural damage at the muscle level also plays a role in this.

Conclusion

There are many different models, but they all have the same goal, which is to optimally prepare players for playing matches. Tactical periodisation is increasingly recognised as an alternative approach to traditional periodisation models. The holistic interplay of all the key training factors (i.e., tactical, technical, physical and mental) means that exercises are chosen that fit the coach’s game model, while also incorporating the other aspects (technical, physical and mental) in order to train as match-specific as possible.

1. Delgado-Bordonau JL & MendezVillanueva JA (2018). Tactical periodization: a proven successful training model. London: SoccerTutor.com.

2. Afonso J et al. (2020). A systematic review of research on tactical periodization: absence of empirical data, burden of proof, and benefit of doubt. Human Movement, 21 (4), 37-43.

3. Delgado-Bordonau JL & Mendez-Villanueva A (2012). Tactical periodization: Mourinho’s bestkept secret? Soccer Journal (May/June), 29-34.

4. Brownstein CG et al. (2017). Etiology and recovery of neuromuscular fatigue following competitive soccer match-play. Frontiers in Physiology, 8, 831-844.

5. Hader K et al. (2019). Monitoring the athlete match response: can external load variables predict post-match acute and residual fatigue in soccer? A systematic review with metaanalysis. Sports Medicine - Open, 5 (1), 48.

Currently the

head of sport science and strength & conditioning, Rainer has held various roles within the performance department of the club. He holds a MSc. in human movement sciences from the Catholic University of Leuven and is certified with the Australian Strength and Conditioning Association (ASCA), as well as the National Strength and Conditioning Association (CSCS). Furthermore, he holds a UEFA A Elite Youth Coaching badge. Questions or comments? Email to r.vangaalappelhof@fcutrecht.nl

INTERDISCIPLINARY PRACTICE INTEGRATING SPORTS NUTRITION & SPORTS PSYCHOLOGY INTO THE RETURN TO PLAY PATHWAY

1. Introduction

The intent of this article is to encourage professionals in sport to embrace disciplines beyond their immediate boundaries of working knowledge. Many specific expertise are prevalent in professional sport. These include but not limited to the Sports Physician, Sports Nutritionist, Sports Psychologist, Exercise Physiologist, Strength and Conditioning Coach, Technical coach and Physiotherapist. Nevertheless, a key question remains as to if outcome objectives of any one discipline benefit from the integration with one or more of the other disciplines? Intuitively, the answer would be “yes” but there remains a lack of clinical studies to advocate interdisciplinary practice.

Musculoskeletal injuries are common in professional Football (soccer) and provide an

excellent model to discuss interdisciplinary approaches. Although, half of injuries are minor, resulting in absences of less than a week, more severe musculoskeletal injuries may result in absences from 11 days up to 50 weeks. Time loss injuries in particular, represent significant challenges to the player as well as supporting medical staff [1]. Having players unavailable for training and match day selection also results in a financial cost for the club. Therefore, speeding up the players return from musculoskeletal injures has both practical and financial implications.

In the case of severe injuries, it is natural that the “return to play” (RTP) pathway will depend, in large , on the boundaries of knowledge and experience of sports medicine practitioners responsible for the player’s recovery. Consensus statements

on returning athletes to sport following injury acknowledge the contributions of sport psychology and sports nutrition. However, there is no specific guidance on how to integrate these two recognised –but often overlooked components of injury rehabilitation – into existing sport medicine approaches [2,3]. In partnership with Medical and Sports Performance teams at FC Barcelona, Manchester City FC, together with leading experts in Sports Nutrition and Sports Psychology we explored the integration of Sports Psychology and Sports Nutrition into an interdisciplinary, medically led, return to play pathway.

An interdisciplinary approach is one in which the expertise of scholars and practitioners fr om different disciplines are brought to bear on the research or clinical problem in question.

Gatorade Sports Science Institute, PepsiCo Life Sciences, UK

2. A Player Centred Approach

First, a leader should be identified to establish a clear direction, while listening and providing support and supervision to the team members during the return to play process. It is recommended that the leader be an experienced medicallytrained individual with a daily presence in team activities. Thus, the team Physician is typically ideally positioned to fulfil this role. To encourage an interdisciplinary approach the leader should establish communication strategies and foster collaborative decision-making. The decision-making process should utilize a player-centered approach [4]. A playercentered approach is characterized by player empowerment and engagement, facilitated by;

• Education about the injury

• Player involvement in the planning of their rehabilitation programs

• Setting of goals

• Ongoing feedback about progress towards players’ rehabilitation goals

• Transparent, honest and frequent communication between the athlete and the treatment team.

3. Sports Nutrition and Sports Psychology

An accurate diagnosis is the first step in the return to play. Typically, the first question asked by the player and coaching staff is, “how long it will take to recover from the injury?” Therefore, explaining the steps required in the return to play timeline is important for managing player and coach anxieties about time-loss concerns. Physicians, Physiotherapists, Sport Psychologists and Sport Nutritionists should collaborate to implement bestpractice goal-setting guidelines with the player that incorporate healing and recovery progressions [5]. The nutrition plan should complement these progressions. Involving the player will help create greater sense of autonomy – that is, a sense of control – over their rehabilitation.

4. Facilitating Interdisciplinary Practice

Interdisciplinary practice can be facilitated by factors which can be easily modified within a Sports Medical team or facility. These include having shared

work spaces. It is common for specific disciplines to have designated work areas, which are separate from others. Simply increasing the proximity of work desks will encourage conversation and sharing of ideas between disciplines. Career professional development should also encourage learning outside of dayto-day expertise. This education can be internal where individuals are given time to share their current practice, or external accredited courses. Finally, appropriate IT platforms should be used to allow shared data access for appropriate stakeholders to record their intervention and opinion on a players development or rehabilitation [6].

5. Practical Consideration

All training, rehabilitation or dietary intervention experienced by athletes are not exclusive to either a physiological or psychological domain. Nevertheless, how many practitioners seek or receive any formal Sports Psychology guidance, to help inform their practice? An injury to a player provides an opportunity for the Sport Nutritionist and Sports Psychologist to interact with the Sports

Return to Play consideration

Acute injury

Body mass management

Inactivity / Non Pitch involvement

Social isolation /inclusion

Role models

Sports Nutrition / Sports Psychology interdisciplinary examples

Dietary intake and supplementation plan as an action to achieve sense of control.

Routine body composition analysis provides short-andlong term goal setting targets.

Meals providing structure to day, avoid episodes of reduced self- worth and binge eating.

Inclusion of players on team eating occasions and having players complete rehabilitation alongside teammates who are training to maintain sense of identity.

Establish “mentor” programme between injured player and role model who successfully overcame similar injury. Sharing of previous experience of both sports nutrition and sports psychology strategies that “helped” the return to play, to facilitate rehabilitation adherence.

Readiness

Nutrition provided prior to exercise and education around role of dietary nutrients enhances players understanding of their body, aiming to facilitate confidence and enhance psychological readiness (confidence, emotions, risk appraisals, approach-avoidance motivations). Education also serves to inform about best sources of information (avoid unqualified advice from internet/ social media).

Medicine department, to demonstrate their impact. Sport Nutrition and Sport Psychology support during an injury often results in players, becoming engaged for the rest of their careers, having experienced the benefit of the support. Providing the players with appropriate nutrition and psychological “tools” to manage the injury process can also extend and remain relevant to when players are back in full training [6]. Table 1 provides some examples of how Sports Nutrition and Sports Psychology can interact during the return to play pathway.

6. Conclusion

The theme of interdisciplinary practice is important as it integrates concepts, theories, methods, and techniques from two or more disciplines, with the aim of advancing fundamental knowledge and practice in professional sport. Although an interdisciplinary approach is theoretically advantageous for the return to play process – it remains uncertain how adopting an interdisciplinary approach facilitates a more effective recovery in comparison to single discipline approaches. Nevertheless, professionals in soccer are encouraged to embrace disciplines beyond their immediate expertise, to understand if or how their own practice could be enhanced by others.

7. Acknowledgments

This article would not have been possible without the collaboration and open mindset of all contributing authors to the “interdisciplinary” manuscript:

James Carter: Gatorade Sports Science Institute, PepsiCo Life Sciences, UK

Graeme Close: Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, UK

Javier Yanguas Leyes, Antonio GomezDiaz: FC Barcelona, Sports Performance Department, FC Barcelona, Spain.

Daniel Medina Leal: Monumental Sports and Entertainment. Washington DC, USA.

Joan Duda: School of Sport, Exercise and Rehabilitation Sciences, The University of Birmingham, UK

Donough Holohan, Sam Erith: Manchester City FC, Sports Science Department, Manchester, UK

Leslie Podlog: School of Kinesiology and Physical Activity Sciences, Faculty of Medicine, Université de Montréal

Disclaimer:

Ian Rollo is an employee of the Gatorade Sports Science Institute, a division of PepsiCo, Inc. The views expressed in this manuscript are those of the author and do not necessarily reflect the position or policy of PepsiCo Inc.

Dr Ian Rollo is principle scientist and head of GSSI International. His current role involves providing sports science and nutritional support for professional soccer clubs and organisations such as FC Barcelona, Manchester City FC and UEFA. Ian also manages clinical research projects and is involved in developing novel technologies to support athlete health and performance. Ian leads the PepsiCo innovation team on healthy aging and Barcelona Innovation Hub Certificate for Sports Nutrition for Football. Finally, he continues to author publications and deliver invited presentations globally. Twitter: @Rollo_I Full bio here

1. Ardern, C.L., P. Glasgow, A. Schneiders, E. Witvrouw, B. Clarsen, A. Cools, B. Gojanovic, S. Griffin, K.M. Khan, H. Moksnes, S.A. Mutch, N. Phillips, G. Reurink, R. Sadler, K.G. Silbernagel, K. Thorborg, A. Wangensteen, K.E. Wilk, and M. Bizzini, 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. British journal of sports medicine, 2016. 50(14): p. 853-64.

2. Wall, B.T., J.P. Morton, and L.J. van Loon, Strategies to maintain skeletal muscle mass in the injured athlete: nutritional considerations and exercise mimetics. Eur J Sport Sci, 2015. 15(1): p. 53-62.

3. Ardern, C.L., N.F. Taylor, J.A. Feller, and K.E. Webster, A systematic review of the psychological factors associated with returning to sport following injury. British journal of sports medicine, 2013. 47(17): p. 1120-6.

4. King, J., C. Roberts, S. Hard, and C.L. Ardern, Want to improve return to sport outcomes following injury? Empower, engage, provide feedback and be transparent: 4 habits! British journal of sports medicine, 2019. 53(9): p. 526-527.

5. Podlog, L. and R. Dionigi, Coach strategies for addressing psychosocial challenges during the return to sport from injury. Journal of sports sciences, 2010. 28(11): p. 1197-208.

6. Rollo, I., J.M. Carter, G.L. Close, J.Y. Leyes, A. Gomez, D.M. Leal, J.L. Duda, D. Holohan, S.J. Erith, and L. Podlog, Role of Sports Psychology and Sports Nutrition in Return to Play from Musculoskeletal Injuries in Professional Soccer: An Interdisciplinary Approach. European Journal of Sport Science, 2020: p. 1-19.

Table 1. Examples of how Sports Nutrition and Sports Psychology can interact during the return to play pathway.

We are sure you will all aware that no one person is ever responsible for a team’s success or failures and that no one person can be an expert in or deliver on everything needed, hence the saying “many hands make light work!”. However, there are also slightly conflicting viewpoints like “too many cooks spoil the broth” or “a little knowledge is dangerous!” so, how do we, as members, of the team behind the team ensure that there is a fully co-ordinated, integrated and well-learnt model of delivery to our players?

The aim of last year’s virtual conference series was to provide some bitesize digestible concepts and case studies to help educate practitioners of aspects not directly related to their own area of expertise and with this in mind this year we hope to bring together such concepts into an aligned and focussed face to face conference now we have the pandemic behind us.

In doing this, Education Co-ordinator, Kevin Paxton, has looked to structure presentations and case studies around the stages of the entire rehabilitation cycle of Clean-up, immediately post-injury, all the way through to the end stage return to Competition.

The conference will incorporate a variety of speaker disciplines that work with an injured player across all the phases of the rehabilitation process such as the Clean-up, acute stages of injury management through to the Clearance of necessary mobility and activation aspects to undertake more intermediate mid stage protocols of Coordination and Change of Direction through to end stage aspects whereby you Chase & Condition certain types of worse case scenarios and then finally onto the return to the 4-corner markers of being ready to Compete.

We hope you will enjoy the wide spectrum of information on show and the engagement of discussing in person how we as practitioners can improve upon the process of;

“Rehabilitation – Clean-Up to Compete”

Many Thanks

Kevin Paxton MSc, ASCC, CSci

MORNING CONTENT

Early to Mid-stage Rehab Phases

AFTERNOON CONTENT

Mid to End stage Rehab Phases

What can organisations do to improve the knowledge base and co-operative work mentality to foster improved interdisciplinary support to athletes in the early phases of an injury?

OVERVIEW

CLEAN-UP

This stage would include any aspects around trauma and acute injury management protocols to ensure no further harm is created and disruption to the diagnosis and prognosis period. It may include examples of pain and swelling management, early tissue remodelling etc.

CONTROL / CLEAR

This stage would include any early methods to restore mobility and muscle function and bridging the gap between the treatment modalities and the gymnasium-based load integration. It may include aspects of interventions with hydrotherapy or bespoke equipment such as isokinetic dynamometry or isometric monitoring.

CO-ORDINATION

This stage would include some of the early loading strategies, functional movement patterning, proprioception etc.

CHANGE OF DIRECTION (i)

This stage would involve some of the force absorption and production exercises and stabilisation training and the preceding pre-planned change of direction drills that would underpin agility-based movements.

What can organisations do to improve the knowledge base and co-operative work mentality to foster improved interdisciplinary support to athletes in the early phases of an injury?

OVERVIEW

CHANGE OF DIRECTION (ii)

This stage would involve some of the plyometric and dynamic stabilisation training and the progression from pre-planned change of direction drills to more reactive agility-based movements.

CHASE & CONDITION

This stage includes any form of adding of external stimuli to promote faster speeds of movement drills and the accumulation of controlled high intensity running.

COMPLETE

This stage focusses on the re-integration requirements for training and the use of certain football specific drills that would assist with any players requiring modification to team training in their return to play phase.

The Rehab T E A M

FMPA CONFERENCE PROGRAMME 2023

Theme Time

9:00

9:45

Topic

Registration & Tea / Coffee

Please visit our trade exhibition.

Opening Address

Speaker OVERVIEW

Eamonn Salmon

Football Medicine & Performance Association

CEO

CLEAN-UP / CONTROL

CO-ORDINATE / CHANGE OF DIRECTION

10:00

10:30

11:00

11:30

12:00

12:30

13:00

14:00

14:30

15:00

PART ONE

CLEAN-UP – CONTROL / CLEAR – CO-ORDINATION / CHANGE OF DIRECTION(i)

Lessons learned about organising a medical department from leaders in football and beyond

Protect & Prognosis of Hip Injuries

Hamstring Injuries – Overview of a rehab blueprint

Tea/Coffee Break

Please visit our trade exhibition

Regaining Mobility & Functional Strength

Pillar Strength to Functional Strength

Buffet Lunch & Refreshments

Please visit our trade exhibition

PART TWO

Dr Andrew Shafik

Lead Academy Doctor – Millwall FC

Professor Damian Griffin

Professor of Trauma & Orthopaedic Surgery

Fearghal Kerin

Physiotherapist – Chelsea FC

Sean Beech

Physiotherapist – Newcastle United FC

Joel Brannigan

Strength & Conditioning Coach

CHANGE OF DIRECTION(ii) / CHASE & CONDITION / COMPETE

Case Study

Speed Mechanics to Agility

Co-ordination to CoD

Linda Fettus

Academy Lead Physiotherapist

Gareth Walton

Performance Coach

Rich Clarke

15:30

16:00

16:30

17:00

Tea/Coffee Break

Please visit our trade exhibition

Power Development to Plyometrics

End stage position specific drills

Closing address

Adam Hearn

Strength & Conditioning Coach

Strength & Conditioning Coach COMPLETE

Dan Kett / Callum Williams

Game Changer Performance

Eamonn Salmon

THE RISE OF MUSCULOSKELETAL IMAGING IN ELITE WOMEN’S FOOTBALL

FEATURE / EDDIE CRAGHILL

Introduction

Women’s football has thrived in recent years with vast increases in grassroots participation, the value of commercial contracts, transfer fees and attendances. Fuelled by England’s success at the Euros, elite players and teams are experiencing unprecedented exposure within mainstream culture. Whilst many are now household names and consequently no stranger to having their picture taken, imaging in a clinical context has an important role in driving the continued growth of elite women’s football.

Injury patterns in elite women’s football

In 2018, the Women’s Super League (WSL) became professional with all players required to be contracted fulltime as part of the licence criteria. The restructure of the top two divisions also saw three clubs affiliated to men’s Premier League teams granted entry into either the WSL or Women’s Championship (WC). In the interim, several WSL teams have relocated their

training facilities to either share with men’s teams or move into purpose built facilities of their own. Consequently, elite women’s footballers now have much greater access to top class medical facilities and personnel.

With increased investment has come increased emphasis on injury prevention and accurate diagnoses to maintain the health and maximise the performance of this cohort of players. Imaging provides a key role in this process. To support this initiative, greater understanding of the variations relating to gender are required to drive forward our understanding of this previously underutilised area.

The WSL produces biannual injury surveillance reports where commonality and severity of injuries can be compared to the average figures for teams in the league. Anterior cruciate ligament (ACL) injuries always feature highly as a proportion of time loss to injury which is consistent with research suggesting women are at least 1.5 times more likely to rupture their ACL than their

male counterparts 2,3. The exact reasons behind this remain controversial with a host of anatomical, physiological, societal, hormonal and training mechanisms proposed.

In response, there has been a big drive towards ACL injury prevention programmes, often with an emphasis towards developing hamstring strength given a demonstrable association between reduced hamstring strength and ACL injury in female athletes compared to controls4. Similarly, a focus on quadricep injuries has also been recommended in female players based on comparative data to male footballers5 Despite this, hamstring and quadricep scores do not significantly differ between women and strength-matched males suggesting other injury mechanisms are at play6

The above must be taken in the context of the higher incidence of quardricep, hamstring and calf injuries compared to ACL injuries. These constitute the most frequently encountered MSK conditions team physicians and physiotherapists will manage in women’s football.

A linked blog ‘How diagnostic imaging is helping to support the rise in women’s football’ was published in the BJSM online in August 20221

Choice of Imaging

The optimum set up for imaging would be a private in-house facility with top end diagnostic equipment readily available. Whilst not necessarily the reality for all, there are ways to improve the process regardless of the setting or the type of imaging. This all starts with selecting the correct modality:

X-Ray

In many cases x-ray is now superseded by MRI and is seldom performed electively. The consequences of exposure to ionising radiation must be carefully considered in a population of females of childbearing age. There are occasions where x-ray can be useful to assess bony structures where MRI and CT are both either contraindicated or those images would be sufficiently distorted by adjacent metalwork to make interpretation impossible.

Ultrasound (US)

UItrasonography has many advantages over other imaging modalities. It is quick, dynamic, does not require exposure to radiation and can be used at the point of care. Not only can a rapid diagnosis be made, US also allows practitioners to monitor the progressive appearances of the structures involved throughout rehabilitation. This may be of particular use in muscle injuries.

When reporting on the findings, it is important to use standardised criteria to ensure that the findings can be consistently replicated. The Delphi-based consensus statement provides a possible framework for this although local guidelines may also exist7. Specific grading systems are also available for injuries to certain anatomical areas such as the medial gastocnaemius8

For those with no previous exposure of musculoskeletal ultrasound, it can be quite daunting picking up a probe for the first time. The modality is unashamedly operator

dependent so does require significant amounts of both practice and patience. It is highly recommended for those working in elite women’s football undertake formal education in this area. A list of courses can be found below.

Access may be another barrier with highend machines being relatively expensive however most elite clubs will already own a device. Alternatively, forming a relationship with the club’s imaging partner or local MSK/ physio services may all be helpful in obtaining access. There are also limitations around which structures can be sufficiently visualised to make a clinical diagnosis, for instance one couldn’t confidently comment on the ACL based on US. Finally, whilst there may be a temptation to do so, it’s important to work within one’s own competency and avoid scanning other areas, e.g. pelvis, unless specifically trained to do so.

Magnetic Resonance Imaging (MRI)

Whilst MRI can be both labour and time intensive, it has a wide range of indications and is often the first-line imaging technique, where resources allow. MRI findings are a key parameter in the common muscle injury classification systems which influence projected time loss to injury,10. The extent of muscle oedema, tendon involvement and loss of tendon tension are all significant prognostic indicators.

to football11,12. It does however have pitfalls, for instance at more distal sites, the crosssectional width of the tear as a proportion may lead to a higher grading and over-estimate the extent of the injury by virtue of the overall width being narrow.

In previous figures, there is a stark contrast between the WSL and WC in terms of days lost to hamstring injuries (575 Vs 931 days) which suggests that professionalism is driving injury prevention at the elite level. In addition to training exposure and access to high quality injury prevention strategies, it may be that limited access to MRI is also driving this time loss if radiological grading if not routinely performed at WC level. This may provide a compelling business case for clubs at that level to increase access to MRI.

Aside from muscle injuries, MRI is also commonly used to assess bony structures. Whilst fractures may be more easily perceptible on CT, bone stress and oedema can be detected on MRI, so they are often used first-line to limit radiation exposure where clinical concerns exist. MRI is also the imaging method of choice for ligamental injuries, either alone or in combination with US in more superficial structures.

Computerised Tomography (CT)

Coronal PD Fat Saturated image of the right knee showing an acute pivot shift injury with an acute lateral condylar bony contusion, which is highly indicative of an associated anterior cruciate ligament (ACL) tear acquired using Canon Medical Vantage Galan 3T MRI.

The British Athletics Muscle Injury Classification (BAMIC) system has been able to demonstrate how application of their criteria can lead to low re-injury rates when applied to hamstring injuries and these findings seem to translate

In football, CT is generally reserved for better characterisation of fractures which are confirmed or suspected on prior imaging. This may also be to aid with surgical planning or to assess ongoing healing. CT uses x-rays to build up a cross-sectional picture and resultantly they produce a much higher quality image of bone and other denser structures however the

ionising radiation involved means their role is otherwise limited in this population.

Of commonly imaged MSK sites, the highest radiation dose is provided by a lumbar spine CT which equates to the same as around seven years of background radiation exposure. Peripheral joints such as the ankle or wrist are much less irradiating at < 1.5 days equivalent exposure13. This can cause a diagnostic quandary in the setting of a suspected pars interarticularis fracture for example. In a symptomatic individual where there is bone stress on an MRI, one would have to carefully consider whether clinical management would be sufficiently altered via a CT in order to justify this in a radiation-sensitive individual. Similarly, there may be an argument not to follow up with CT given a bony union may not be necessary for restoration of function.

Dual Energy X-ray Absorptiometry (DEXA) With Relative Energy Deficiency in Sport (RED-S) being increasingly recognised in Women’s Football14, having an accurate modality to establish both body composition and bone density is vital. DEXA is superior to both skinfold measurements and bioelectrical impendence analysis (BIA)15 and plays an important role in promoting high performance and assessing training response. Whilst DEXA involves radiation exposure, this is significantly less than standard x-rays and it’s potentially appropriate to repeat annually for bone density assessment where indicated16 Familiarity with the interpretation of T and Z scores is advised. Novel alternatives such as the Echolight may also play a role in measuring bone density in scenarios such as pregnancy where the use of any radiation is contraindicated.

Conclusion

A by-product of the continued growth of women’s football, there has been a revolution in teams’ access to imaging facilities. There is already evidence this is starting to influence both the incidence and burden of injuries at the elite level. Careful test selection and a greater understanding of how the various injury classifications apply to this cohort will enhance this process and lead onto future areas of research. As leaders at the forefront of women’s football medicine, we have a duty to accelerate this drive towards imaging equality.

Ultrasound Courses

MSc Medical Ultrasound – FMPA

https://www.brunel.ac.uk/study/ postgraduate/musculoskeletal-ultrasoundpgcert

PGCert MSK US - Sports Medicine Ultrasound Group (ultrasoundtraining.co.uk)

Acknowledgements:

The author would like to acknowledge two of his Radiology Consultant colleagues, Prof Waqar Bhatti and Dr Gulraiz Ahmad, for their long-standing contributions to his learning and development within this topic.

Dr Craghill is the Women’s Team Support Doctor at Manchester United where Canon Medical Systems UK is the club’s official imaging partner.

Dr Craghill is currently enrolled on the Sports Medicine Ultrasound Group (SMUG) Post-graduate Certificate in Medical Ultrasound.

1) How diagnostic imaging is helping to support the rise in women’s football - BJSM blogsocial media’s leading SEM voice (bmj.com)

2) Mayhew L, et al.. Incidence of injury in adult elite women’s football: a systematic review and meta-analysis. BMJ Open Sport Exerc Med. 2021 Jul 13;7(3):e001094

3) Montalvo AM, Schneider DK, Silva PL, et al ‘What’s my risk of sustaining an ACL injury while playing football (soccer)?’ A systematic review with meta-analysis. British Journal of Sports Medicine 2019;53:1333-1340

4) Myer GD, Ford KR, Barber Foss KD, et al. The relationship of hamstrings and quadriceps strength to anterior cruciate ligament injury in female athletes. Clin J Sport Med. 2009 Jan;19(1):3-8.

5) Larruskain J et al. A comparison of injuries in elite male and female football players: A five-season prospective study. Scand J Med Sci Sports. 2018 Jan;28(1):237-245

6) Nimphius S et al. Comparison of Quadriceps and Hamstring Muscle Activity during an Isometric Squat between Strength-Matched Men and Women. J Sports Sci Med. 2019 Feb 11;18(1):101-108

7) Mederic M Hall MM, Allen GM, Allison S, et al. Recommended musculoskeletal and sports ultrasound terminology: a Delphi-based consensus statement. British Journal of Sports Medicine. Mar 2022, 56 (6) 310-319; DOI: 10.1136/bjsports-2021-105114

8) Pedret C, Balius R, Blasi M et al. Ultrasound classification of medial gastrocnemious injuries. Scandinavian Journal of Medicine & Science in Sports. 2020. 30; 2456 - 2465.

9) Mueller-Wohlfahrt H, Haensel L, Mithoefer K, et al. Terminology and classification of muscle injuries in sport: The Munich consensus statement. British Journal of Sports Medicine 2013;47:342-350.

10) Pollock N, James SLJ, Lee JC, et al. British athletics muscle injury classification: a new grading system. British Journal of Sports Medicine 2014;48:1347-1351.

11) Pollock N, Kelly S, Lee J, et al. A 4-year study of hamstring injury outcomes in elite track and field using the British Athletics rehabilitation approach. British Journal of Sports Medicine Published Online First: 14 April 2021. doi: 10.1136/bjsports-2020-103791

12) Tears C, Rae G, Hide G, et al. The British Athletics Muscle Injury Classification grading system as a predictor of return to play following hamstrings injury in professional football players. Physical Therapy in Sport. 2022. 58, 46-51. https://doi.org/10.1016/j. ptsp.2022.08.002.

13) Patient dose information: guidance - GOV.UK (www.gov.uk)

14) Keay N, Craghill E, Francis G. Female Football Specific Energy Availability Questionnaire and Menstrual Cycle Hormone Monitoring. Sports Injr Med. 2022: 6: 177. DOI: https://doi. org/10.29011/2576-9596.100177

15) Tornero-Aguilera JF, Villegas-Mora BE, Clemente-Suárez VJ. Differences in Body Composition Analysis by DEXA, Skinfold and BIA Methods in Young Football Players. Children (Basel). 2022 Oct 28;9(11):1643. doi: 10.3390/children9111643. PMID: 36360370; PMCID: PMC9688600.

16) DEXA Use in Sports Medicine - The Faculty of Sport and Exercise Medicine (fsem.ac.uk)

SPORT-RELATED CONCUSSION IN HIGH SCHOOL SOCCER: FEMALES HAVE HIGHER

INJURY RATES AND LONGER RETURN-TOSPORT THAN MALES

FEATURE

Introduction

/ ABIGAIL C. BRETZIN, PHD, ATC

Sport-related concussions (SRC) are common in athletes.2 Likely due to the world-wide participation, soccer is one of the leading sports in which athletes experience SRC; and for females in particular, soccer often has the highest SRC incidence.2-4 Therefore soccer’s high SRC incidence, and the large number of participating athletes, warrants continued study into the sport-specific underlying causes of injury to help direct interventions for prevention.5 Our article leveraged a large state-wide surveillance system lead by a public school athletic system in the USA (Michigan High School Athletic Association (MHSAA)) to study the clinical incidence of SRC and the causes of injury in high school soccer occurring across a state in the midwestern region of the United States. Further, in this study of over 80,000 high school-aged soccer athletes, we compared the clinical incidence of SRC and head injury causes between males and females.

High School Head Injury Surveillance

The MHSAA is a private, not-for-profit athletic association that oversees over 1,500 private and public junior high/middle schools and high schools across the state of Michigan, USA. Athletes in grades 6 through 12 participate in this level of competition. The MHSAA implemented a head injury surveillance system starting in the 201516 academic year, in which participating schools are mandated to record SRC events and circumstances of each head injury that occur in MHSAA sanctioned sports. To date, there are approximately 23,000 SRC events that resulted from sanctioned sport participation reported into the surveillance system. Thus, this is a valuable resource to identify the causes and incidence of injuries in high school sports.

SRC Injury Rates Higher for Females Relative to Males

Injury rates are an important measurement tool that can be used to monitor SRC incidence over time. In our study, we specifically calculated the incidence proportion, or the total number of athletes

that sustained a concussion relative to the total number of participating athletes each season. Specifically, in the study period combining three academic years (2016-17 through 2018-19) female SRC incidence was 2.40 (95% Confidence Interval (CI): 2.25, 2.55) per 100 athletes, and the overall SRC incidence for males was 1.27 (95% CI: 1.17, 1.38) per 100 athletes. SRC incidence for the individual academic years are presented in Figure 1. Our findings highlighted that in soccer, a sex-comparable sport in which rules and equipment are largely the same between the male and female game, females exhibited SRC injury rates that were almost two times (Rate Ratio: 1.88, 95% CI: 1.69, 2.09) the rate relative to males (Figure 2).

Our study is not the first to identify that females display a higher rate of SRC relative to males. For example, in an early study using the MHSAA surveillance database we found females had SRC clinical incidence rates were 1.6 times greater than males in soccer.3 In another study focused on SRC in high school soccer, the authors reported that SRC diagnoses were 84% higher in females compared to males.6 Similarly, in the collegiate setting, females also had 1.6 times higher SRC rates in soccer compared to males.2 To date, research consistently demonstrates females have higher SRC incidence compared to males in soccer.

Research Investigator, Department of Emergency Medicine Injury Prevention Center, University of Michigan

1. Sport-related Concussion (SRC) Rates and 95% Confidence Intervals (CI) in High School Soccer.

Figure 3. Significant differences in cause of SRC between males and females in soccer (p <0.001).

Figure 2. Rate Ratios (RR) comparing Male and Females Sport-related Concussions (SRC).

Injury Mechanisms: Differences between Males and Females

Determining causes of injury may, in part, aid in explaining why females have higher SRC incidence in soccer. In our study, the most common causes of SRC in high school soccer were from contact with a person (38.2%) and contact with an object (37.0%). However, when comparing injury causes between males and females, we found significant differences (p < 0.001). Specifically, more female SRCs resulted from contact with an object (41.9%) followed by contact with a person (31.9%); whereas, almost half of male SRC resulted from contact with a person (48.4%) followed by contact with an object (31.7%). Importantly, a limitation in our analyses included truly identifying the object that caused the injury; however, due to limited equipment used in soccer, we concluded many of these instances corresponded to contact with the ball. These results are consistent with other studies focused on soccer, that report males more often sustain SRC from person to person contact, and females’ SRCs are often caused by equipment or apparatus, including the ball.2 Further, a recent review identified that females had 1.7 times higher header-related SRC rates compared to males.7 Therefore, when determining SRC prevention interventions, researchers, policy makers, and coaches should consider the most common causes of SRC, while also understanding the differences in mechanisms between males and females to target sport- and sex or gender-specific prevention.

Rationale and Importance of Male and Female Differences

There are many reasons to consider why females have higher SRC incidence than males in soccer. One consideration is that SRC reporting behaviours and symptom-reporting is different between males and females, and between injury causes.8-11 Further, there are anatomical and biological differences between males and females (e.g., neck strength and circumference, muscle activation, head size, hormones and menstrual cycle phase, axonal size and structure) that may influence the body’s ability to resist against oncoming head impacts or response to forces placed on the brain during a head impact.12-18 Another important consideration relating to the higher incidence of SRC in females is that sport-medicine coverage is often not similar between male and female athletes, especially in lower levels of participation like the high school setting. For example, Athletic Training services are often prioritised for male sports, which is exemplified by higher percentages of Athletic Trainer involvement in early SRC evaluations in high school males compared to females.19 This is especially important, as access to Athletic Trainer – allied health care providers in sports medicine involved in evaluation, management, and rehabilitation of athletic injuries – can improve SRC prevention and outcomes, and the lower availability to Athletic Trainers in females may place them at risk for worse SRC recovery outcomes.20 In fact, in our study, we found females in high school soccer less often had an Athletic Trainer in their first SRC evaluation and also displayed longer time to return to sport.1 Thus, these results should motivate improving early access to sports medicine professionals during soccer practices and competitions, like athletic trainers, and promoting equal access between males and females.

Conclusion

This report summarizes our recent study that identified different causes of injury between males and females, and that youth female soccer athletes had higher SRC incidence

and longer return-to-play time compared to males.1 We also summarized the multidimensional, existing evidence that provides rationale as to why females display higher injury rates and longer recovery times. Together, these findings suggest SRC prevention in females may be targeted toward ball-to-head contact mechanisms; whereas, prevention in males might be directed towards limiting person-to-person mechanisms. In addition, these results emphasize female and male soccer athletes display different recovery timelines, which should be a consideration when returning athletes back to sport following SRC. Furthermore, these findings should motivate continued and increased presence of sports medicine professionals to provide acute evaluation of injuries, particularly in female athletes.

1. Bretzin AC, Covassin T, Wiebe DJ, Stewart W. Association of Sex With Adolescent Soccer Concussion Incidence and Characteristics. JAMA Netw Open. Apr 1 2021;4(4):e218191. doi:10.1001/jamanetworkopen.2021.8191

2. Chandran A, Boltz AJ, Morris SN, et al. Epidemiology of Concussions in National Collegiate Athletic Association (NCAA) Sports: 2014/152018/19. Am J Sports Med. Feb 2022;50(2):526-536. doi:10.1177/03635465211060340

3. Bretzin AC, Covassin T, Fox ME, et al. Sex Differences in the Clinical Incidence of Concussions, Missed School Days, and Time Loss in High School Student-Athletes: Part 1. Am J Sports Med. Jul 2018;46(9):2263-2269. doi:10.1177/0363546518778251

4. Kerr ZY, Chandran A, Nedimyer AK, Arakkal A, Pierpoint LA, Zuckerman SL. Concussion Incidence and Trends in 20 High School Sports. Pediatrics. Nov 2019;144(5)doi:10.1542/peds.2019-2180

5. Chandran A, Nedimyer AK, Register-Mihalik JK, DiPietro L, Kerr ZY. Comment on: “Incidence, Severity, Aetiology and Prevention of Sports Injuries: A Review of Concepts”. Sports Med. Oct 2019;49(10):1621-1623. doi:10.1007/s40279-019-01154-1

6. Chandran A, Elmi A, Young H, DiPietro L. Determinants of concussion diagnosis, symptomology, and resolution time in U.S. high school soccer players. Res Sports Med. Jan-Mar 2020;28(1):42-54. doi:10.1080/15438627.2019.1590834

7. Dave U, Kinderknecht J, Cheng J, Santiago K, Jivanelli B, Ling DI. Systematic review and meta-analysis of sex-based differences for concussion incidence in soccer. Phys Sportsmed. Feb 2022;50(1):11-19. doi:10.1080/00913847.2020.1868955

8. Wallace C, Smirl JD, Zetterberg H, et al. Heading in soccer increases serum neurofilament light protein and SCAT3 symptom metrics. BMJ Open Sport Exerc Med. 2018;4(1):e000433. doi:10.1136/bmjsem-2018-000433

9. Miyashita TL, Diakogeorgiou E, VanderVegt C. Gender Differences in Concussion Reporting Among High School Athletes. Sports Health. Jul 2016;8(4):359-63. doi:10.1177/1941738116651856

10. Sullivan L, Molcho M. Gender differences in concussion-related knowledge, attitudes and reporting-behaviours among high school studentathletes. Int J Adolesc Med Health. Oct 24 2018;doi:10.1515/ijamh-2018-0031

11. McAllister-Deitrick J, Beidler E, Wallace J, Anderson M. Concussion Knowledge and Reporting Behaviors Among Collegiate Athletes. Clin J Sport Med. Mar 11 2020;doi:10.1097/JSM.0000000000000833

12. Caccese JB, Buckley TA, Tierney RT, et al. Head and neck size and neck strength predict linear and rotational acceleration during purposeful soccer heading. Sports Biomech. Nov 2018;17(4):462-476. doi:10.1080/14763141.2017.1360385

13. Tierney RT, Higgins M, Caswell SV, et al. Sex differences in head acceleration during heading while wearing soccer headgear. J Athl Train. 2008;43(6):578-584.

14. Bretzin AC, Mansell JL, Tierney RT, McDevitt JK. Sex differences in anthropometrics and heading kinematics among Division I soccer athletes. Sports Health. Mar/Apr 2017;9(2):168-173. doi:10.1177/1941738116678615

15. Dolle JP, Jaye A, Anderson SA, Ahmadzadeh H, Shenoy VB, Smith DH. Newfound sex differences in axonal structure underlie differential outcomes from in vitro traumatic axonal injury. Exp Neurol. Feb 2018;300:121-134. doi:10.1016/j.expneurol.2017.11.001

16. La Fountaine MF, Hill-Lombardi V, Hohn AN, Leahy CL, Testa AJ. Preliminary Evidence for a Window of Increased Vulnerability to Sustain a Concussion in Females: A Brief Report. Front Neurol. 2019;10:691. doi:10.3389/fneur.2019.00691

17. Wunderle K, Hoeger KM, Wasserman E, Bazarian JJ. Menstrual phase as predictor of outcome after mild traumatic brain injury in women. J Head Trauma Rehab. Sep-Oct 2014;29(5):E1-8. doi:10.1097/HTR.0000000000000006

18. Esopenko C, de Souza N, Conway F, et al. Bigger Necks Are Not Enough: An Examination of Neck Circumference in Incoming College Athletes. J Prim Prev. Oct 2020;41(5):421-429. doi:10.1007/s10935-020-00600-5

19. Bretzin AC, Zynda AJ, Wiebe DJ, Covassin T. Time to Authorized Clearance from Sport-Related Concussion: The Influence of Healthcare Provider and Medical Facility. J Athl Train. Dec 22 2020;doi:10.4085/JAT0159-20

20. Vedung F, Hanni S, Tegner Y, Johansson J, Marklund N. Concussion incidence and recovery in Swedish elite soccer - Prolonged recovery in female players. Scand J Med Sci Sports. May 2020;30(5):947-957. doi:10.1111/sms.13644

UNRAVELLING HIP & GROIN PAIN

Introduction

Acute and chronic hip & groin injuries are common in football. Studies have found groin injury to be the fourth most common injury affecting soccer players.

During a season around half of players will experience groin pain1. If you ask a team in any given week, about 20% of the playing squad will have some groin problems - even more at the beginning of a season2

Despite their prevalence, assessment of these injuries can be challenging for various reasons:

· The complexity of the regional anatomy

· The broad spectrum of injury footballers are exposed to due to the aerobic-anaerobic switching, explosive, kicking, and multidirectional nature of the sport

· Overlap in clinical presentation

· Co-existence of pathologies (indeed, one injury can be a risk factor for another - groin injury evolution)

· Lack of clinical test specificity

This is a brief synthesis of up-to-date evidence and ‘coal-face’ experience to hopefully help clinicians better analyse groin injury & navigate assessment, with the focus principally on chronic presentations in adults.

FADDIR (flexion-adduction-internal rotation) test – joint pathology

This is my ‘go-to’ test at the beginning of the assessment, alongside the more functional ‘hop test’ and screening of the lumbar spine.

Given that FADDIR is sensitive3 (ie if it’s negative, it means an intra-articular source is unlikely to be the pain culprit), starting with this can be helpful in taking common

arthrogenic conditions off the diagnostic table eg femoroacetabular impingement (FAI), osteoarthritis and labral pathology.

However, no test is foolproof. It is possible to have a positive FADDIR with proximal femur stress fractures into FADDIR compression, as well as with irritable symphysis pubis pain and acute iliopsoas tears with haematoma.

Bone stress injury

The ‘hop test’ is another helpful screening test here.

If it’s negative, then I feel you can be comfortable knowing you are not dealing with a high-grade stress fracture eg neck of femur or the pubic body/ramus.

If positive, patients will be ‘shut down’ due to pain inhibition with poor power output and cadence.

True stress fractures are uncommon in the football population but we need to be vigilant if the player is adding in extra conditioning sessions, playing multiple sports (especially at school age level), or has RED-S risk factors.

FEATURE / JAMES NOAKE

The reactive muscle

Local extension of periosteal inflammation in stress fractures can occur in a muscle group adjacent to the culprit bone (e.g. adductor longus, magnus, obturator or iliopsoas).

This can then masquerade and confuse as the ‘primary’ injury with muscle spasm and pain on palpation resisted testing through the region.

Pubic overload

Pain (aching, throbbing) can be lower abdominal and groin, but also radiate into the genitals and perineal region (not just the domain of nerve entrapment syndromes).

There is no single resistance test that’s specifically helpful in identifying pubicrelated groin pain.

Local tenderness identified on firm glide of the symphysis and palpation of adjacent bone is important (know your surface anatomy ‘pubic clock’ (image) 4) but confusingly it can be non-provocative in a small number of patients.

In these cases, you may need to escalate the assessment to dynamic functional movements that more reliably generate stress across the symphysis.

The opposite also occurs - it’s a sensitive area and can be sore in many. It’s essential to clarify, “is this your typical pain?”.

MRI pubic oedema is common in the asymptomatic higher-impact multi-directional sports population as well - as always imaging should be interpreted cautiously in the context of the history and examination.

Midline pain concept

If lower abdominal and groin pain flits from side to side, then often it’s being generated from a ‘midline’ structure (less likely than being a symmetrical/bilateral injury), so should focus your assessment at the pubis.

If pain is centrally driven eg symphyseal joint or pubic overload, the ‘hop test’ can be positive when testing the contralateral side – ie ground reaction forces transferred across the irritable bony pelvis midline.

The alternative is a discogenic problem (again, a ‘midline’ driver). Somatic discogenic pain can wrap around the pelvis into the hips and groin. Modic changes may be seen on lumbar MRI.

Figure 7. Falvey 2009

Is it the ‘hip flexor’?

Generally, isolated iliopsoas driven pain is over-diagnosed. This may be partly due to reliance on false positive palpation sensitivity of the muscle-tendon unit either above the inguinal ligament or below it towards the lesser trochanter in Falvey et als 4 pathoanatomical ‘groin triangle’.

The triangle concept is itself a useful platform on which to build a structured approach to groin assessment.

Reactive hip flexor paratendinitis might be seen more frequently in the football population vs an endurance sport groupwith bursts of intense activity or explosive drills, or in a spike of preseason fitness testing. However, Iliopsoas accounted for only 2.6% of injuries in field-based sports in a large prospective study 5

Acute tears of the iliopsoas occasionally occur, but other ‘flexors of the hip’ are far more commonly injured eg adductor or rectus femoris in football.

Look harder for a deeper primary driver for secondary hip flexor irritation – such as dysplasia, FAI, anterior labral pathology, joint synovitis or proximal femur bone stress (image) - particularly in those with a more chronic, insidious presentation, overtraining history and those participating in concurrent endurance activities.

Modified Thomas & Cross Over tests

Although commonly employed, I feel this has little diagnostic utility, at least outside of muscle length testing. Potentially all subsets of groin pain can be provoked in this position; passive hip extension and isometrically testing the iliopsoas from outer range can concurrently stress the pubic symphysis and anterior pubic aponeurosis, adductor origin, anterior hip joint, inguinal and rectus abdominis structures.

As an extension of this, a positive ‘CrossOver’ test in a Thomas position (ipsilateral pain reproduced on contralateral resisted iliopsoas testing) is also relatively nondiscriminatory.

It is however considered an indicator of poorer prognosis in inguinal and pubicrelated groin pain This could potentially prove useful in monitoring the severity of symptoms and the readiness for returning to sport 6

The PLAC (pyramidalis-anterior pubic ligament-adductor longus complex)

Although commonly employed, I feel this Historically, ‘pubic aponeurosis’ injuries

have been recognised as a common source of groin pain5 in field sports. They are welldefined on MRI with a groin protocol.

These have been alternatively labelled as ‘rectus abdominis-adductor longus aponeurosis’ tears.

Contemporary cadaveric studies have redefined the anatomy in this zone8 and the PLAC concept has evolved (image).

The PLAC classification potentially allows for a more consistent radiological definition of injury to the soft tissues around the pubis and may help stratify management (surgical vs non-surgical) based on future research.

PLAC injuries are typically described in a traumatic setting ie adductor origin avulsion; however those injuries that fail to heal adequately, or are poorly rehabilitated, have the potential to develop into a more chronic injury that behaves in an enthesopathic manner.

To complicate matters, pectineus muscle tears (yet another assistant hip flexor and adductor!) frequently co-exist with PLAC injury9

Inguinal pain

Despite strides being made towards developing consensus around sporting inguinal injury 10,11 - including its terminology & surgical managementinevitably a level of disagreement remains around which incompetent tissue is at fault, and thus clinician uncertainty as to the key focus of assessment and which tests are valid.

Certainly, the label ‘sportsman’s hernia’ is outdated now, not least, because the pathology is not a true hernia.

Some experts even consider inguinalrelated groin pain a ‘disease without pathology’.

Pain felt in the lower abdomen (often ‘tearing’, elastic band-like) and around the pubic tubercle is the consistent feature, and commonly provoked by Valsalva, coughing & sneezing, as well as executing core, abdominal & trunk resistance work 7

Resisted crunches, oblique crunches and leg raises all stress irritable inguinal structures. Rectus abdominis insertional tendinopathy is often cited under these test circumstances but is rare (acute rectus muscle tears are more common).

Again, as with the adductor group, these active tests and palpation may be falsely positive in the presence of pubic overload/ stress.

Superficial ring invagination

Myriad tests are described in the peripubic zone to assess for inguinal pathology subsets 12, some of which are intimate and potentially uncomfortable, and there is questionable inter-examiner reliability - try and keep it as simple and unintrusive as possible.

Superficial ring invagination (plus added Valsalva) can be useful in experienced

hands in eliciting ‘inguinal disruption’ pain through the medial margins of the canal.

Again, compare contralaterally and confirm it is their typical pain.

Be aware not all inguinal related groin pain comes from local superficial ring pathology; examine the tissues of the canal superolaterally.

Classic inguinal hernia

The direct or indirect inguinal hernia can still exist and cause discomfort in the younger sporting patient, but symptoms tend to be less activity related and functionally disabling. Important to not overlook this as it’s potentially easily treated surgically.

If no clear bulge or palpable cough impulse at the deep ring or Hesselbach’s triangle in supine, stand them up and repeat the assessment – this is more sensitive with the assistance of gravity.

Ultrasound is the imaging modality of choice to rule out; dynamic MRI is also being utilised at some centres.

Peripheral nerve entrapment/ irritation

This can occur independently, or co-exist with ‘inguinal disruption’ cases, due to compression, traction, inflammation, or fibrosis in the inguinal canal.

Neuromas are well-recognised entities by groin surgeons and can complicate inguinal surgery eg mesh repair.

Diffuse, poorly localised neuropathic pain around the medial groin, proximal thigh and genitals often with a dysaesthetic or hyperaesthetic quality.

Be aware there is a wide inter-personal variation and sensory territory overlap across ilioinguinal, genitofemoral and iliohypogastric nerves.

Tinel’s test at the irritable nerve level (further assisted by ultrasound localisation) along its anatomical path may illicit typical radiating pain.

Masqueraders and red flags

Arguably the most important area.

I have seen multiple cases where patients have been worked up extensively for genitourinary (classically prostatitis in pubic related groin pain), gynaecological or gastrointestinal conditions etc before the penny drops that lower abdominal and groin symptoms are mechanical & musculoskeletal in nature.

Unfortunately, I also see numerous serious ‘red flag’ conditions masquerading as sports conditions on an annual basis, including pelvic and abdominal organ malignancy.

Always remember to ask your systems questions – for example, menstrual change, dyspareunia, bloating (gynae / pelvic); haematuria, dysuria, discharge (genitourinary); diarrhoea, bleeding (GI)- as well as exploring constitutional symptoms (eg weight loss, fever, night sweats).

Be wary of symptoms unrelated to activity & sport patterns and progressing despite offloading.

The SI joint (sacroiliitis in spondyloarthropathy) can also drive groin, ramus and perineal pain – but is usually associated with concurrent gluteal pain.

Controversy remains around SI joint testing, but I feel that the tests are useful as a cluster, in particular femoral thrust to rule out SIJ involvement 7

Pelvic enthesopathies also occur in axial spondyloarthritis, affecting adductor, pubic and iliac spines - mimicking sports-related tendinopathy.

Be suspicious of latter half-night pain & morning stiffness, particularly in a younger demographic < 45 years old and use the SCREEN’DEM tool.

SCREEND'EM BEFORE YOU TREAT'EM

A clinical tool to help identify spondyloarthropathy (SpA) in patients with tendinopathy.

SKIN

6-42% of patients with psoriasis develop psoriatic arthritis.

COLITIS OR CHROHN'S

Arthritis is one of the most common extra-intestinal manifestations of inflammatory bowel disease. The prevalence of SpA in patients with Chrohn's is estimated to be 26% at 6 year follow up.

RELATIVES

There is a strong relationship between SpA and HLA-B27 positive patients.

Family members of patients with SpA who are

1. Thorborg K, Rathleff MS, Petersen P, et al. Prevalence and severity of hip and groin pain in sub-elite male football: a cross-sectional cohort study of 695 players. Scand J Med Sci Sports 2015

2. Harøy J, Clarsen B, Thorborg K, et al. Groin Problems in Male Soccer Players Are More Common Than Previously Reported. Am J Sports Med 2017.

3. Combining results from hip impingement and range of motion tests can increase diagnostic accuracy in patients with FAI syndrome. Anders Pålsson et al. Knee Surg Sports Traumatol Arthrosc. 2020

4. The groin triangle: a pathoanatomical approach to the diagnosis of chronic groin pain in athletes. E C Falvey, A Franklyn-Miller, P R McCrory. BJSM. 2008.

5. Athletic groin pain (part 1): a prospective anatomical diagnosis of 382 patients—clinical findings, MRI findings and patient-reported outcome measures at baseline. É C Falvey, E King et al. 2. BJSM 2015.

EYES

Acute anterior uveitis (AAU) can cause a painful, red eye with photophobia and blurred vision. 40% of patients presenting with idiopathic AAU have undiagnosed SpA. 50% of patients with AAU are HLA-B27 positive and >50% of these have SpA.

EARLY MORNING STIFFNESS

Inactivity related stiffness that lasts for more than 30 minutes is suggestive of inflammatory disease.

NAILS Nail lesions occur in 87% of SpA patients and include:

- small depressions in the nail (pitting)

- thickening of the nails -painless detachment from the nail bed (onchylosis).

DACTYLITIS

Sausage like swelling of the digits is a hallmark sign of psoriatic arthritis, occuring in 50% of cases.

ENTHESITIS

98% of SpA patients have at least one abnormal enthesis. The most common sites are the Achilles tendon, plantar fascia and patellar tendon.

MOVEMENT & MEDICATION EFFECT

SpA patients report improvement with activity but not with rest, and a favourable response to NSAIDs. @pdkirwan

Created by Paul Kirwan

HLA-B27 positive have a 16-fold increase chance of developing ankylosing spondylitis if they are also HLA-B27 positive. ISBN/EAN: 978-90-75823-92-9,

6. An Investigation of the Relationship between Diagnosis and Objective Tests in the Assessment of Athletic Groin Pain. Boland M, King E et al. Byrne D, Franklyn-Miller A. Sports Medicine Department, Sports Surgery Clinic, Dublin.

7. Clinical Examination, Diagnostic Imaging, and Testing of Athletes With Groin Pain: An Evidence-Based Approach to Effective Management. Reiman, Thorborg et al. Journal of Orthopaedic & Sports Physical Therapy. Volume 48, number 4, April 2018

8. Schilders E et al. The pyramidalis-anterior pubic ligament-adductor longus complex (PLAC) and its role with adductor injuries: a new anatomical concept. Knee Surg Sports Traumatol Arthrosc. 2017.

9. Schilders, E., Mitchell et al. Proximal adductor avulsions are rarely isolated but usually involve injury to the PLAC and pectineus: descriptive MRI findings in 145 athletes. Knee Surg Sports Traumatol Arthrosc 29, 2424–2436 (2021.

10. ‘Treatment of the Sportsman’s groin’: British Hernia Society’s 2014 position statement based on the Manchester Consensus Conference. Aali J Sheen, B M Stephenson et al. BJSM 2013.

11. Doha agreement meeting on terminology and definitions in groin pain in athletes. Adam Weir, Peter Brukner et al BJSM. 2015.

12.Clinical examination for athletes with inguinal-related groin pain: inter-examiner reliability and prevalence of positive tests. Willem M P Heijboer, Zarko Vuckovic, Adam Weir et al. BMJ Open Sport & Exercise Medicine. 2022.

13. https://www.groinpainclinic.co.uk/groinpain/nerves-affected-in-chronic-groin-pain

14. SCREENDEM – Paul Kirwan

INTRODUCING AQUA THERMAE

Aqua Thermae is an aquatic sports and hydrotherapy specialist company who represent SwimEx pools in the UK, Ireland and across Europe. We have also supported SwimEx pools by project managing several installations across the Middle East.

Our clients include the British Ministry of Defence, British embassy abroad, Wolverhampton Wanderers, Stoke City, Reading Football Club and we are currently installing two SwimEx pools at Queens Park Rangers including a recovery deep water cold plunge pool with an energy efficient heat pump chilling system.

We also installed the SwimEx 600T with automated underwater treadmill at the Strive Elite sports academy in Jersey who have hosted the British And Irish Lions, England rugby, Leicester Tigers, Bath rugby and Sale rugby clubs on training camps.

The success of premium hydrotherapy is founded on premium quality equipment and design specifications that seek to exceed industry guidance wherever possible. Richard Bishop, Technical Director, has been in the industry for 36 years and composed the award winning technical paper for the Institute of Swimming Pool Engineers and recently gave a talk on sports hydrotherapy to the Institute.

Whether you are looking for a brand new hydrotherapy suite or seeking to upgrade your existing filtration and water treatment facilities, AquaThermae are available for support across the UK and Europe providing a simple health check and service to existing

pool equipment, or new design consultation through to full supply and installation of elite sports hydrotherapy facilities.

Well maintained hydrotherapy resources will protect the athletes and in many cases deliver accelerated recovery ensuring players return to the field sooner but with resilience to help prevent repeat injuries.

Aqua Thermae aim to design well and deliver more in the following areas:

Pools

SwimEx pools are hand crafted, marine grade pools built in the same way an ocean racing yacht would be made. They are custom built to order and often branded with club team colours. SwimEx was designed over 40 years ago to deliver professional sports and medical recovery pools. We also install the SwimEx range of hot and cold deep water plunge pools and ice baths. The pools can arrive to site pre assembled at the factory or assembled on site inside existing buildings where space is a challenge. We can also design, specify and install conventional pools to the clients requirements.

Filtration

We aim to minimise chemical inputs by filtering the pool water more effectively with advanced glass media which delivers water filtered ten times finer than traditional sand filters. These filters are then enhanced with the addition of treatments to further screen the water. By removing the physical debris from the water the water will need less Chlorine to combat the contamination.

Water Flow

We use energy saving invertor controlled filtration pumps to reduce operational costs whilst ensuring optimum flow rates for filtration and back wash cleansing of filter systems.

Water Treatment

Our water treatment systems are specified for each pool and deliver accurate Chlorine and pH control of the pool water to deliver pristine safe water for the athletes and players. The systems are supported with advanced UV systems for further peace of mind. Our systems are fully internet compatible enabling remote monitoring and technical support without the need to attend site.

Climate Control

One of the largest cost factors with a hydrotherapy suite will be the heating energy costs, and so we offer a design service to ensure the climate control of the pool heater, air temperature and pool hall humidity of 60% are kept in harmony and balance. This will minimise evaporation from the pool surface which in turn dramatically reduces the energy consumption.

Training

We can also deliver professional pool plant training for your on site teams to ensure the hydrotherapy pools are operated and maintained to deliver the optimum safe quality water conditions possible. The training can be delivered on site and made site specific to to be relevant to the equipment installed on your facilities. More effective operation often leads to lower operational costs.

Standards of work

All works and advise given is in line with current Health Protection Agency (HPA), Pool Water Treatment Advisory Group (PWTAG) and or the Institute of Swimming Pool Engineers (ISPE) and or Swimming Pool Allied Trade Association standards (SPATA).

You can contact Richard Bishop MISPE direct if you would like to discuss a health check on your existing facilities or considering a future hydrotherapy project.

richard@aquathermae.co.uk

Telephone 07484 070765

USE OF ISOKINETICS IN THE REHABILITATION PROGRAMME FOLLOWING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION (ACLR)

Structured rehabilitation protocols for ACLR patients based on healing rates, biomechanical factors and principles of muscle physiology are key to achieving successful rehabilitation. Isokinetics can play a key part throughout this.

Maximum Protection Phase (0-4 weeks post-surgery)

Ideally, patients will have been isokinetically screened prior to injury, so clinicians can utilise this baseline data, alternatively the non-injured leg can be used as comparison.

In this early stage of recovery, the CPM role of the Isokinetic Dynamometer will be the primary purpose of rehabilitation. This will allow the patient to regain range of movement alongside active exercise followed by initiating low-level quadriceps/hamstring concentric contraction. This can be used in collaboration with the use of neuro-muscular stimulators such as Compex units.

Initial position will be in sitting but can be progressed to prone lying towards the end of this phase. Once passive movement exceeds 50% knee range of movement sub maximal work commences.

The range of movement will need to be limited to between 90°to 40° of knee flexion to protect the graft alongside the use of the anti-shear attachment, to give maximum protection.

Close kinetic chain attachments are available on most isokinetic units allowing a low level of patient torque which is an important issue at this stage of recovery.

In regard of the non-operated leg, full range maximal isokinetics can commence once the patient has 90° of range in the ACLR knee.

Moderate Protection Phase (4-12 weeks post-surgery)

In this phase, patients will continue to progress the intensity of the concentric sub maximal workload of the quadriceps (Sitting - 90°40°) and hamstrings (Prone lying – Full active range).

Also, the donor graft site (hamstring or patella tendon) needs to be loaded concentrically before moving onto sub maximal eccentrics to ensure adhesion formation and scarring is kept to a minimum.

‘When can I run?’, often the first any player asks, is usually a time rather than criterionbased decision at around 12-14 weeks postoperatively.

Bilateral isokinetic testing at 12 weeks post operation, utilising torque with body weight data, ensures this is a clinical based decision. This timeline may need to be extended if other surgery has also been necessary.

Range of movement is limited to between 90°to 40° of knee flexion, test speeds are 180° and 300° per second and the anti-shear device is used on both limbs. Familiarisation with test speeds should commence at least a week before testing if isokinetics haven’t been part of first 11 weeks of rehabilitation.

It’s important to determine which data targets the non-operated leg can achieve per individual. Ideally, professional athletes should be able to achieve six out of ten parameters before progressing to the running stage of rehabilitation.

Minimum Protection Phase (12-36 weeks post-surgery)

Isokinetic rehabilitation will continue with appropriate adjustments to the relative variables. Velocity Spectrum Protocols predominantly using the 180°-300° window of speeds, 1-3 bouts, 5-9 sets and 6-10 repetitions as variables, with a weekly endurance session introduced of sets involving 20-40 repetitions with use of 4-6 sets.

At approximately 24 weeks and after a positive clinical/functional assessment, a full range bilateral concentric/concentric quadriceps/hamstrings tests can be re-introduced with comparison to the preinjury data.

Isokinetic concentric/eccentric loading can then be introduced to supplement other field-based work with further testing at 36 weeks. This data can then be utilised to calculate a mixed ratio of eccentric hamstring/concentric quadriceps which ideally should be between 1.1-1.2.

Further testing should be considered at 12-, 18- and 24-months to monitor a full recovery both in concentric and eccentric modes, ensuring maximum protection.

Conclusion

Rehabilitation is a long road. Isokinetic dynamometry is a useful tool to increase range of movement and strength in both a rehabilitation and testing format throughout recovery.

IPRS Mediquipe are the UK distributors of the Biodex Isokinetic Dynamometer System 4, trusted worldwide and used by some of the UK’s biggest football clubs. To learn more, visit www.IPRSMediquipe.com or scan the code.

Fig 1. Biodex System 4 Isokinetic Dynamometer.

Solarsport is the optimal sunscreen that performs at the highest level. It is our mission to revolutionise everyday sun protection.

Born of family passion and proven in sporting excellence it is designed for maximum simplicity and versatility because stylish UV protection matters everyday and everywhere. And, for everyone.

Developed alongside elite sportspeople such as Lee Westwood and Stuart Broad, the formula is designed to enable athletes to perform at the highest level.

Why is sun protection important in elite sport?

Athletic performance can drop by up to 15% as the bodies defence mechanism saves the athlete from sun damage.

By wearing an SPF 30 as part of a daily routine, your athletes can maintain peak condition. Sun protection has been off the radar in sport for far

too long, with rates of melanoma dramatically increasing 140% since the 1990s. This needs intervention. More education at all levels of sports organisations can make suncare as much of a daily routine as training, diet and mental health.

Solarsport is partnering with FMPA to protect players from the dangers of the sun and skin. Everyone needs sun protection, everyday.

Elite to everyday

Solarsport was originally developed for the needs of elite athletes to

help them perform at their optimal level. It’s easy application not only makes the product ideal for sport, but also for everyday use. With our best formula, you can protect yourself and your family with a simple spray, everyday.

We understand how difficult it can be, with big bottles of expensive cream that are hard to apply and cause greasy skin. With Solarsport, you don’t have to worry due to ease of application and travel sized bottles. Your family’s skin can be protected with minimal effort, and with the same formula that elite athletes trust on their skin everyday.

Protecting you and your family in every sport, every sun sport, every dry sport and every fun sport.

Solarsport Protection is Performance

LEGAL Compromise agreement

“...I took your advice and have been working with the FMPA lawyer on the conclusion of my contract. Martin from his swift response on day one has been a real rock on my side and he has stayed in contact with me at regular intervals. His professionalism and knowledge of the football contract has helped me to be both realistic and hopeful regarding my case. We are now at the final stages of discussions with the club and the financial and emotional support I have has come through my contact with Martin. I am also immensely grateful to the FMPA for your help and support at this difficult time. At a low point in my life both the FMPA and Martin have helped me get the contractual situation sorted with as little fuss as possible and that’s been important to me and my family.”

Head of Medicine, League 2

Contract review

“...I just wanted to drop you an email to let you know how helpful Martin has been this last week. Although away, and with poor signal, he consistently made the effort to respond quickly to my questions when the club came back with updated terms. I believe his guidance has been fundamental to my negotiations.”

Head Physiotherapist, Premier League

“...Thank you so much. Really appreciate your help with this, it’s brilliant that the FMPA offer this service to its members. This stuff can be a minefield.”

Lead Sports Scientist, Premier League