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Pictured: Wolverhampton Wanderers’ Ricardo Ivan Cavaleiro lies on the pitch injured
INJURY SURVEILLANCE WITHIN THE CHAMPIONSHIP FEATURE/REMI MOBED, MEN’S TEAM PHYSIOTHERAPIST – THE FOOTBALL ASSOCIATION Injury and illness studies have been performed within the sporting related context for a number of years. As researchers collect and analyse data, we as clinicians ‘on the ground’, are constantly searching for ways to reduce injury risk, incidence and severity of injuries subjected to athletes.
W
ithin the modern game of football, time loss to a player due to injury or illness can have mammoth consequences. Therefore it is important that we track / monitor those that occur in both match and training activities so that we can have a greater understanding of them and put into place interventions to attempt to reduce risk to our athletes. The Football Association (FA) injury and illness surveillance study (IISS) commenced in the Football League Championship in the 2013/14 season. The study (which is voluntary) has been running for three consecutive seasons and during this time period an average of 14 clubs out of the 24 has chosen to take part. Below is a brief summary of the article with added comments from the author(s). It is important to recognise that due to the limited data collected throughout the three seasons, some of the relative percentages for injury incidence are based on a limited number of injuries and the reader should
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interpret this with caution. The good news is, since the start of the study in the 2013/14 season, injury trends are decreasing within The Championship. The split between whether they are occurring in matches (55%) or training (45%) is negligible over the last few seasons. This split of match and training injuries is similar to other seasonal studies that have been performed in football (1). The author(s) would like to believe that moving forward, the trends of injury patterns (particularly within the training environment) will continue to fall. As science and our knowledge of load management is evolving, clinicians now have easier access to GPS objective data to advise coaches on how to load monitor the professional player during the training days between fixtures. The difficulty clinicians have, is that with such a congested fixture list there is minimal time for full player recovery between games. Sports Science and medicine departments have recently demonstrated how elite football clubs are using different methods
and tools to monitor their players between games to assist in ‘readiness to train’ and play in these congested periods (2). Monitoring such as this will hopefully reduce injury incidence and severity over the coming seasons. Gabbett et al, 2016 have shown how important ‘load management’ can be, showing that injury spikes can occur when athletes are offloaded due to a ‘deconditioning affect’. Could this be a reason for an injury spike within the pre-season months of The Championship, when players come off a period of rest into an intense pre-season conditioning period? This could also explain as to why there could be lower numbers of injuries in the second half of the season when compared to the first as players become fitter, stronger and more tolerant to loading as a season progresses. Others would argue that these lower injury numbers within the second half of the season could be due to decreasing intensity of training patterns whilst teams and coaches are trying to preserve their players through the long
football medic & scientist season. Or is it because clubs are simply not progressing to final stages of cup competitions and the gruesome play-off games in the final stages of the league? Common sense would tell us that less exposure would equal fewer injuries. So is the answer to decrease fixtures? It is a discussion which is taking place, one that is much more complicated to give a simple yes or no answer to. What are the steps that need to be taken? Although incidences of injuries appear to be decreasing, severity of those injuries is increasing. When considering together both match and training, average severity (days lost) increasing from 43.7 in the 2013/14 season to above 50 in the 2015/16 season. How can this be? The game itself is changing. There is a trend showing that match intensity is increasing, with players performing more sprints and consequently more accelerations and decelerations. This would in itself mean that forces being produced, specifically around the contact/tackle areas are higher than they have ever been before. Contact related injuries surrounding the tackle area are increasing (26.5% in 2013/14 season compared to 29.6% in 2015/16 season). Are these small changes significant? We need further studies and larger number of clubs/ players to take part to truly answer this question. Non-contact injury events have also increased by approximately 9%. There is some exciting research into the type of pitch we are exposing our players to, with questions being asked if pitch surfaces and injury incidence/ risk and severity are related? The harder pitches make the faster paced game for the fans more exciting, but are we increasing risk to our athletes and the forces we are subjecting them to? It is something that is being looked into but we are far from finding the solid answers to yet another question into the complicated multifactorial conundrum of injuries. One thing that does remain true is that as with many other running based field sports, hamstring injuries remain one of the most common, and cause the most burden (7-8), with 14% of all training and 17.4% of all match injuries occurring to the posterior thigh. Calf muscle/tendon injuries are also high (match 6.8% vs training 8.7%). With these figures, it is of no surprise that we should be considering our focus of Strength and conditioning programmes and monitoring on the posterior chain of the lower limb. The balance of trying to fit in these programmes/monitoring around an already hectic match and training schedule can be difficult. Quadriceps injury during training (7.8%) is of interest discussion. Common (although not true of all clubs) is for players to practice shooting and goal scoring at the end of sessions. A working hypothesis could be that pre-fatigue from the session is causing more quadriceps injuries than necessary. Should we adopt standpoints that have been taken in sports such as cricket and only allow players to deliver ‘X’ amount of balls post session? Conclusion The overall picture of injuries and illnesses within The Championship is looking good.
Table 1: Percentage of injuries as a function of activity and onset
Activity, % of injuries (Number of injuries) Match Onset
Training
All Activities^
13/14
14/15
15/16
13/14
14/15
15/16
13/14*
14/15
15/16
(n=313)
(n=366)
(n=223)
(n=282)
(n=281)
(n=159)
(n=602)
(n=652)
(n=384)
Acute
71.2
83.6
83.4
64.5
69.8
67.9
67.9
77
76.6
Gradual Onset
28.1
16.4
16.6
35.1
30.2
32.1
31.6
23
23.4
All Injuries
100
100
100
100
100
100
100
100
100
*Missing detail for 3 injuries; ^ includes ‘Not Known’ activity injuries
Table 2: Incidence of Injury
Incidence; injuries /1000 player hrs (95% Confidence Interval (CI))
Match Training
13/14
14/15
15/16
All Years
26.7
23.5
21.2
23.8
(23.7-30.1)
(21.1-26.2)
(18.5-24.3)
(22.2-25.5)
5.6 *
3.8 **
3.0***
4
(4.9-6.4)
(3.3-4.3)
(2.5-3.6)
(3.7-4.3)
^Match incidence calculations include injuries sustained/reported during ‘warm up’ pre-match. * In 2013-2014, there was no training exposure data from three clubs and only partial exposure data from three clubs, thus injury data corresponding to the missing exposure data were not included in training incidence calculation. ** In 2014-2015, there was no training data from two clubs and only partial exposure data from eight clubs, thus injury data corresponding to the missing exposure data were not included in training incidence calculation. *** In 2015-2016, there was no training data from two clubs and partial exposure data from one other club, thus injury data corresponding to the missing exposure data were not included in training incidence calculation
Graph 1: Average number of injuries per club per month
Table 3: Average Severity of Injury
Average severity (days) (95% CI)
Match Training
13/14
14/15
15/16
All Years
26.2
31.2
32.9
29.9
(20.5-31.9)
(25.0-37.4)
(25.6-40.2)
(26.2-33.6)
17.5
24.2
26.6
22.1
(14.2-20.8)
(20.6-27.8)
(19.6-24.6)
(19.6-24.6)
*Three players retired through the injuries they sustained, thus severity data were not included for these injuries. (Two knee meniscal/cartilage injuries and one talus/calcaneus fracture).
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Pictured: Birmingham City’s Cheick Keita receives treatment from Physio Pete Shaw during the game against Wigan Athletic in March 2017.
Injury surveillance studies like these are vital for our continual understanding of football so that we as clinicians can do our best to implement strategies to reduce both injury and illness to the athletes. Reducing the risk of injury and illness cannot be limited to only looking into one factor. Understanding the complete player and their full needs and athletic profiles must be taken into account. With the demands of the game changing we need to make sure we continue to ask ourselves questions and challenge each other in our thoughts and practices to keep up with change. Studies like this allow us to have the knowledge of the injury patterns that are occurring both throughout the season and during games. Knowing these patterns can help drive training/loading programmes. By having studies like this, it allows us to ask questions and for governing bodies to make decisions on fixture lists and the congested season. Do we need to reduce them? Is there enough evidence yet to support these types of decisions? Probably not, but the continuing great work of the club’s medical staff is slowly but surely building a good case. Further and wider studies must be undertaken in English football in order for us to have data that is more reliable and relevant. Only then will we have a truer picture of what is occurring at all levels of the game. Acknowledgments The FA would like to thank Ailleen Taylor and Colin Fuller as well as the valuable support and work provided by the Championship clubs’ medical and sports science staff during the collection of the data analysed in this report and Benchmark 54 for their help in the collation of the data for a number of the championship clubs.
Table 4a: Match injuries (Competitive and 1st team friendly matches)
Percentage of ALL match injuries (n=902) Injury
All Years, %
Hamstring muscle/tendon
17.4
Calf muscle/tendon
6.8
Adductor muscle/tendon
5.8
Ankle - lateral ligament
5.5
Thigh Haematoma
4.8
Table 4b: Training injuries (All training injuries irrespective of whether corresponding training exposure data was received)
Percentage of ALL training injuries (n=722) Hamstring muscle/tendon
All Years, %
Calf muscle/tendon
14.0
Quadriceps muscle/tendon
8.7
Adductor muscle/tendon
7.8
Groin muscle injury/soreness (unspecified)
7.5
Thigh Haematoma
4.6
REFERENCES 1. Ekstrand, J., 2014. UEFA Elite Club Injury Study, Season 2012/2013 Report. 2. Thorpe, R.T., Strudwick, A.J., Buchheit, M., Atkinson, G., Drust, B., Gregson, W. (2015). Monitoring fatigue during the in-season competitive phase in elite soccer players. International journal of sports physiology and performance, 10 (8) p958-964. 3. Gabbet et al (2016). The acute:chronic workload ratio in relation to injury risk in professional soccer. Journal of Science and medicine in sport,. 4. Hickey, J., Shield, A.J., Williams, M.D. and Opar, D, A. (2014). The financial cost of hamstring injuries in the Australian Football League. 5. England Professional Rugby Injury Surveillance Project. 2014/15 season report. Available at http://www.englandrugby.com/mm/Document/General/General/01/31/72/86/ InjurySurveillanceReport_2014-15_SINGLE_22Mar16_English.pdf
For those who would be interested in the full summary, please email injury.surveillance@thefa.com
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