Football Medic & Scientist - Issue 20 by Football Medicine & Performance Association

football medic & scientist The official magazine of the Football Medical Association

Issue 20 Spring 2017

In this issue: Injury Surveillance Fitness for Fans Heat & Hypoxia Hamstring Injuries

Exclusive:

AÊļçǝŇĭǝ ļëÊĜ Details announced for our 2017 Conference & Awards

FMA FOOTBALL MEDICAL ASSOCIATION SPONSORED BY

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Contents

FMA FOOTBALL MEDICAL ASSOCIATION SPONSORED BY

Welcome 4

Members’ News

Features 6

Non-Steroidal Anti-Inflammatory Drugs Dr. Craig Rosenbloom

Injury Surveillance In The Championship Remi Mobed

12 The Use Of Heat And Hypoxia Carl Wells, Ben Mackenzie & Ian Aylward 16 There Are Many Good Reasons To Screen Your Athletes But Predicting Future Injury Is Not One Of Them Nicol van Dyk, Arnhild Bakken, Stephen Targett & Roald Bahr 24 FMA Conference 2017 Details 30 FMA Register 34 Fitness For Fans Dr. Christopher Bunn 36 Hamstring Injuries In Professional Football Players Mr Nicola Acampora & Dr. Karl New 45 Where Are They Now? Jim McGregor

CHIEF EXECUTIVE OFFICER In reflecting upon this season, this edition appears to summarise, and reflect, just what a great year this has been. The start of 2017 in particular was a pivotal moment in our development and saw the announcement of our new website coincide with a more intrinsic use of social media. Putting the two together and then highlighting the websites new features – forum, FMA Register, interactive member facility to update profiles, user friendly access and clearer design – meant several developments coming together at the same time. The result was remarkable with an average in excess of 12, 000 hits per week on the website! This clearly illustrates that our audience is not just confined to our growing membership but has a reach way beyond to include anyone interested in medicine and science within the football industry and indeed sport. Our database also currently stands at around 15,000 which again demonstrates our reach among practitioners in particular, who are linking with us through a variety of social media platforms. So, the interest in the FMA is healthy and robust and these figures are not only an interesting demographic but are of real value to us. The FMA register of practitioners has a specific target audience from which to spring from. Within the first 2 months of launch in January, over 200 members joined and listed their profile on the site, clearly understanding the potential value to their services. The second phase, now underway is to bring on board health care providers and also create access to the “millions” of players at grassroots level. This a challenging task but we are well on the way to achieving our goals Our project lead Angela has more details in this edition. The Conference is also well underway and delegates are signing up weekly. Once again, we have a terrific line up speakers who work at the very top of their game and there is something at this event that all medics, therapists and scientists can learn from and take with them into their Clubs. This year we have the support of the FA who are set to host a question and answer session with a manager/coach which should be illuminating and informative and a real chance to hear what is important on both sides. But we are not finished yet. Expect further announcements regarding the event over the coming weeks and I very much look forward to seeing you all there. Eamonn Salmon CEO Football Medical Association

Football Medic & Scientist Gisburn Road, Barrowford, Lancashire BB9 8PT Telephone 0333 456 7897 Email info@footballmedic.co.uk Web www.footballmedic.co.uk

COVER IMAGE Burnley’s Dean Marney comes off injured and is assisted by Head Physiotherapist, Alasdair Beattie. Nick Potts/PA Archive/PA Images Football Medical Association. All rights reserved. The views and opinions of contributors expressed in Football Medic & Scientist are their own and not necessarily of the FMA Members, FMA 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 FMA. For permissions contact admin@footballmedic.co.uk.

Chief Executive Officer

Eamonn Salmon Eamonn@footballmedic.co.uk

Executive Administrator

Lindsay McGlynn Lindsay@footballmedic.co.uk

Project Manager

Angela Walton Angela@footballmedic.co.uk

Design

Oporto Sports - www.oportosports.com

Marketing/Advertising

Charles Whitney - 0845 004 1040

Photography

PA Images, Francis Joseph, Football Medical Association

Contributors

Dr. Craig Rosenbloom, Remi Mobed, Carl Wells, Ben Mackenzie, Ian Aylward, Nicol van Dyk, Arnhild Bakken, Stephen Targett, Roald Bahr, Dr. Christopher Bunn, Mr Nicola Acampora, Dr. Karl New, Jim McGregor

Publisher

Academy Print & Design www.academy-print.co.uk

football medic & scientist

members’ news

MEMBERS’ NEWS FMA MEMBER EFFECTS CHANGE WITH THE SCOTTISH FOOTBALL ASSOCIATION

couple of months ago St Johnstone Physiotherapist, Tony Tompos, wrote a blog calling for better management of athletes who suffer with concussion. Following discussions with the Football Medical Association (FMA) and the Scottish Football Association (SFA), John Fleming (SFA Referee Chief) and Dr John Maclean (SFA Doctor) recently held a meeting to discuss his blog and the incidents which he reflected on, and the management of concussed athletes. Thanks to Tony’s blog the SFA have added to the rules of the current ‘Concussion Protocol’ by reaffirming that referees must receive specific confirmation by the team doctor that the player is able to continue following a head injury and have also added the following rules: The procedure has recently been reviewed by the Referee Committee and the Professional Game Board, and it has been agreed to extend the procedure by adding the following text: ~ In the event that a player declines assessment, and the medical staff (Team Doctor/Physiotherapist) have ongoing concerns regarding the well-being of a

player for a suspected concussion and wish to assess the player, they should request the opportunity to assess the player via the match officials at the initial stoppage or at an appropriate stoppage in play thereafter In such circumstances the match official(s) should be alerted to the request for an assessment either via a player, team official or via another match official using the communication equipment. Once this request has been received, the referee will permit the medical staff to enter the field of play to assess the player, despite his reluctance to receive this attention. The player would then be required to leave the field of play as per Law 5.

Quotes Tony, “I believe these revised rules will enable better care and management for the potentially concussed athlete. There is still work to be done in this area and although this is a positive step, I would like to think that the possibility of instant video replays and HIA’s may be something that is implemented in the future but for now, I do think its a good step forward!” Well done Tony on taking up this issue and driving it to this conclusion.

UNIVERSITY PARTNERSHIPS

iscussions have been underway recently with the the University of Central Lancashire (UCLAN) exploring the potential for the FMA to partner with educational establishments in order to best offer members appropriate higher degrees or diplomas.

FMA member Mark Leather, senior lecturer at the University has facilitated discussions in the initial phase and will

look to direct any relationships that emerge in the coming months.

Partnering with Universities is a way to strengthen our careers guide and also gives us the chance to discuss the structure and delivery of courses taking in to account the time constraints of members working in the game. Updates will follow as we have them.

LIGHTFORCE LASERS

ightfForce have joined the FMA as Business Club Member for the remainder of the season.

“LightForce are a leading medical device company offering the latest in advanced laser products. Lightforce have joined the FMA as Business Club Member and will have a presence on website and in our magazine. Focusing on therapeutic and pain management markets, LightForce offers superior products, developed by laser scientists and engineers with years of experience designing and manufacturing medical technology.” Lightforce will be exhibiting at this years conference and awards event.

BACOBAN JOINS

he FMA is delighted to welcome Bacoban as a business partner for the remainder of this season and the full 2017/18 season ahead. Bacoban is an effective and proven biocide that controls and prevents infections and the company is headed by former professional footballer Jim Melrose. The company will be exhibiting at our Conference in May where they will be able to demonstrate just how unique their product is in this market.

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Pictured: West Ham Unitedâ&#x20AC;&#x2122;s Michail Antonio lays on the ground after he picks up an injury during the Premier League match at Bournemouth in March 2017.

NON-STEROIDAL ANTI-INFLAMMATORY DRUGS FEATURE/DR. CRAIG ROSENBLOOM - LEYTON ORIENT FC Excessive anti-inflammatory drug use in elite sports has been well documented with football having some of the highest rates of use of any sport (1)

on-steroidal anti-inflammatory drugs (NSAIDs) are commonly used painkillers used to treat soft tissue injuries due to their anti-inflammatory and analgesic effects. Commonly used drugs in this group include but are not limited to ibuprofen, naproxen, and diclofenac. The largest data source relating to football currently available is from the FIFA World Cups. Since the 2002 World Cup any medication that has been administered by a team physician to a player 72 hours prior to a game has been recorded (2). At the last World Cup in Brazil, just over half of the 736 players present at the competition took an NSAID during the tournament. Nearly a third of all players used an NSAID prior to every match regardless of whether they played, which is roughly 7 out of the 23 players per national squad per match (3). Much higher rates of medicine use were seen in older players, and also players from the South American and Asian Confederations (3). There was no difference in

rates of use in injured vs. non injured players, or between players participating in the match and substitutes who did not play at all (4). Looking across the game as a whole - similar rates of NSAID use were found at the 2003 and 2007 FIFA Womenâ&#x20AC;&#x2122;s World Cup (4). In a younger population players at the 2005 and 2007 Under-17 and Under-20 World Cup tournaments, 43% of participants used an NSAID during the competition (4). Unfortunately no recent data has been published. At the FIFA Futsal World Cup between 2000 and 2012, 45.7% of players took at least one NSAID during the competition, with a quarter taking at least one NSAID prior to every game (5). Efforts have been made to try and reduce rates of NSAID use, and before the 2010 FIFA World Cup the FIFA Medical Assessment and Research Centre (F-MARC) campaigned to reduce the use of NSAIDs during the tournament. Team physicians were informed about the potential side effects, and the detrimental effects on recovery after exercise

and tissue healing (4). Despite this; rates of NSAID use per match at the 2010 World Cup increased 5% compared to 2006 (6). At the 2014 World Cup NSAIDs were the most commonly taken physician provided medication at the tournament, accounting for over 40% of all medicines taken. Diclofenac was by far the most popular NSAID accounting for 60% of use, with selective COX-2 inhibitors accounting for 16.4% (3). The medical team are an important influence given the prescription only nature of most NSAIDs. In the 2002 FIFA World Cup one country used more than one type of NSAID per player per match throughout the entire tournament (4). During a FIFA Futsal World Cup the players from two entire teams were all prescribed the same NSAID by their team physician before every game (5). Physician prescribed figures might underestimate NSAID use as this does not include any self administered medication by the players themselves (4). Data from domestic leagues is scare. In

football medic & scientist Scottish professional football between 2008 and 2012, NSAIDs were the most commonly declared medication on doping control forms accounting for 30%. Players over the age of 26 had a higher rate of use than younger players (7). A study of the top two tiers of Italian professional football found that 93% of players used an NSAID in the previous year, with 86% currently using one, and 22% using one for more than 60 days per a year (8). Why does it matter? NSAIDs work by inhibiting prostaglandin synthesis in the COX pathway. Despite their frequent use, NSAIDs are not suitable for the treatment of all soft tissue injuries as inflammation can play an important role in tissue repair. Animal and human studies have shown that inhibiting prostaglandin synthesis can delay tendon healing, and can increase non-union rates in fractures (9, 10). If NSAIDs are used during the destructive phase of muscle damage the remodelling phase can be limited which can increasing recovery times (9). It is well recognised that even short term NSAID use can have serious health risks (11). These include kidney, gastro-intestinal, and cardiovascular complications. Increasingly strong links between NSAID use and low sodium blood levels (hyponatraemia) are being described (12). Gastro-intestinal side effects include ulceration, erosion, perforation, and bleeding of the stomach. Symptoms can include abdominal pain/cramps, nausea, and indigestion. 30-70% of athletes using NSAIDs report one of these side effects (13). During exercise blood flow through the kidneys can increase by 50%, however NSAIDs reduce kidney blood supply. Reducing kidney blood supply during a time of increased kidney demand can result in permanent kidney damage. An American study associated up to 10% of all kidney failure to NSAID use (9). The increased cardiovascular risks that NSAID use has been shown to have is very concerning, especially that of diclofenac which was the most commonly prescribed NSAID at the World Cups (14). What can I do? If an oral NSAID is indicated then evidence would recommend using the smallest dose, for the shortest time, with attention being made when selecting which one to use. Alternatives to oral NSAIDs include topical preparations (patches and gels) which only accounted for 7% of NSAID use at female and youth World Cups (15). Studies have shown that these might be suitable alternatives for use in acute soft tissue injuries and have low adverse event rates (16). Alternative oral analgesics are an underused option, with paracetamol only accounting for 5% of all medication used at World Cups (4). Further research is needed to look at rates of use in the professional domestic game, including what is the perceived benefit of taking it. Has taking NSAIDs simply become a normal behaviour for players and the medical staff?

Pictured: Tottenham Hotspurâ&#x20AC;&#x2122;s Kieran Trippier clashes with Wycombe Wanderersâ&#x20AC;&#x2122; Myles Weston, leading to Tripper suffering an injury .

REFERENCES 1. Thuyne WV, Delbeke FT. Declared use of medication in sports. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. 2008;18(2):143-7. 2. FIFA Anti-doping [Available from: http://www.fifa.com/mm/document/tournament/ competition/01/47/38/17/regulationsfwcbrazil2014_update_e_neutral.pdf. 3. Vaso M, Weber A, Tscholl PM, Junge A, Dvorak J. Use and abuse of medication during 2014 FIFA World Cup Brazil: a retrospective survey. BMJ Open. 2015;5(9). 4. Tscholl PM, Vaso M, Weber A, Dvorak J. High prevalence of medication use in professional football tournaments including the World Cups between 2002 and 2014: a narrative review with a focus on NSAIDs. British journal of sports medicine. 2015;49(9):580-2. 5. Pedrinelli A, Ejnisman L, Fagotti L, Dvorak J, Tscholl PM. Medications and Nutritional Supplements in Athletes during the 2000, 2004, 2008, and 2012 FIFA Futsal World Cups. Biomed Res Int. 2015;2015:870308. 6. Tscholl PM, Dvorak J. Abuse of medication during international football competition in 2010 - lesson not learned. British journal of sports medicine. 2012;46(16):1140-1. 7. Mercer A, Hillis W. Medication and supplement use in Scottish professional football. Scottish Medical Journal. 2014;59(3):E30-E. 8. Taioli E. Use of permitted drugs in Italian professional soccer players. Br J Sports Med. 2007;41(7):439-41. 9. Lippi G, Franchini M, Guidi GC. Non-steroidal anti-inflammatory drugs in athletes. British journal of sports medicine. 2006;40(8):661-3. 10. Mehallo CJ, Drezner JA, Bytomski JR. Practical management: nonsteroidal antiinflammatory drug (NSAID) use in athletic injuries. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. 2006;16(2):170-4. 11. Day RO, Graham GG. Republished research: Non-steroidal anti-inflammatory drugs (NSAIDs). British journal of sports medicine. 2013;47(17):1127. 12. Wharam PC, Speedy DB, Noakes TD, Thompson JMD, Reid SA, Holtzhausen L-M. NSAID Use Increases the Risk of Developing Hyponatremia during an Ironman Triathlon. Medicine & Science in Sports & Exercise. 2006;38(4):618-22. 13. Waterman JJ, Kapur R. Upper gastrointestinal issues in athletes. Current sports medicine reports. 2012;11(2):99-104. 14. Pawlosky N. Cardiovascular risk: Are all NSAIDs alike? Canadian Pharmacists Journal : CPJ. 2013;146(2):80-3. 15. Tscholl P, Feddermann N, Junge A, Dvorak J. The use and abuse of painkillers in international soccer: data from 6 FIFA tournaments for female and youth players. The American journal of sports medicine. 2009;37(2):260-5. 16. Kuehl KS. Review of the efficacy and tolerability of the diclofenac epolamine topical patch 1.3% in patients with acute pain due to soft tissue injuries. Clin Ther. 2010;32(6):1001-14.

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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.

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

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

76.6

Gradual Onset

28.1

16.4

16.6

35.1

30.2

32.1

31.6

23.4

All Injuries

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***

(4.9-6.4)

(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)

*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).

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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Pictured: Coventry Cityâ&#x20AC;&#x2122;s Marcus Tudgay lies injured during their League One match versus Milton Keynes Dons in March.

THE USE OF HEAT AND HYPOXIA IN THE PHYSICAL CONDITIONING

OF LOAD COMPROMISED PLAYERS FEATURE/CARL WELLS, BEN MACKENZIE & IAN AYLWARD Science and medical practitioners utilise novel training approaches in an attempt to optimise the physical condition of their athletes.

ne such contemporary strategy is the periodised manipulation of the external training environment to increase the physical challenge and subsequent physiological response (Jebeau et al., 2016). When such an approach is applied acutely, the outcome is a reduction in the mechanical work performed for comparable or elevated cardiovascular effort (Vogt & Hoppeler, 2010). Such an intervention is particularly beneficial for dynamic load compromised players where due to either stage of rehabilitation or injury history, it is necessary to ensure the mechanical stress they are exposed to during periods of intensive conditioning or competition is reduced while maintaining aerobic fitness. Hypoxia and heat are two environmental stressors commonly used to increase physiological strain for a reduced physical output (Garrett et al., 2010). The limited availability of atmospheric oxygen in moderate to severe hypoxia (<15%

Fig 1 Average power output (W/Kg) for each 4 minute bout in hypoxic (13.5% atmospheric oxygen) and neutral (20.9% atmospheric oxygen) environments

football medic & scientist atmospheric oxygen) and redistribution of blood flow via vasodilation in heat (> 30 degrees Celsius) compromises the delivery of oxygenated blood to the exercising muscles, reducing physical output capabilities. Despite the manipulation of environmental temperature and oxygen content having such significant impact on the physical load placed upon an athlete, it has not been established how cardiovascular and physical output responses may vary between these two different physiological stressors. Due to the contrasting physiological adaptations induced by acute heat and hypoxic exposure, it may be the case that one environment is more appropriate than the other in achieving the desired physical stimulus for a load compromised player to optimise training gains. To help address this paucity in the knowledge, published findings (Mackenzie et al., 2016) collected in the Human Performance Laboratory at the National Football Centre St. Georgeâ&#x20AC;&#x2122;s Park will be presented in an attempt to provide guidance on the appropriate application of heat and hypoxia in the physical conditioning of load comprised athletes.

Fig 2. Average power output (W/Kg) for each 4 minute bout in heat (40 degrees Celsius) and neutral (24 degrees Celsius) environments.

The Study With institutional ethics approval, data was collected from 30 professional football players who attended the National Football Centre on the Professional Football Player Association intensive rehabilitation scheme. The aim of the study was to investigate whether differences exist in power output and heart rate during cycling in either severe heat or hypoxia compared to environmentally neutral conditions. Players were allocated to either a heat or hypoxic exercise group, with the groups matched for aerobic fitness and training history. The heat and hypoxic groups performed the same exercise challenge of four bouts of maximal-intensity cycling for four minutes; with each bout separated by two minutes of passive recovery. The heat group performed the exercise challenge at 40 degrees Celsius, 50% humidity and 20.9% oxygen, while the hypoxic group exercised at 23 degrees Celsius, 50% humidity and 13.5% oxygen. The levels of hypoxia and heat used in the study were selected as they have both previously been classified as severely challenging environmental conditions (Sunderland et al., 2008; Swapnil et al., 2010). All players repeated the exercise challenge 48 hours later in environmentally neutral conditions (23 degrees Celsius, 50% humidity and 20.9% oxygen). For each four minute cycling bout in each environmental condition, average power output (W/Kg) and heart rate (b.min-1) were recorded. Analysis of variance was performed to measure mean differences between exercise bouts and environmental conditions.

Fig 3. Comparison of percentage power decrement for each 4 minute exercise bout between the hypoxic and heat environments.

Pictured: West Ham Unitedâ&#x20AC;&#x2122;s Pedro Obiang receives treatment for an injury during the Premier League match against Leicester City at London Stadium.

The Findings Power Output Profiles As expected, analysis of the data revealed power output in hypoxia (Figure 1) and heat (Figure 2) for each exercise bout was lower than that achieved in neutral conditions. When the decrease in power output was averaged across the four bouts to provide a power degradation percentage for the entire session in each environment, the reduction in power output in hypoxia and heat compared to neutral conditions was similar at 9.8 and

10.4% respectively (Figure 3). However, further analysis of the data revealed a difference in the pattern of power degradation over the four bouts between the two environments. In hypoxia, power output was 7% lower than in neutral conditions during the first exercise bout. This discrepancy increased to 10% by the second bout before plateauing to between 10 â&#x20AC;&#x201C; 12% for the remaining two bouts. In contrast, power output during the first exercise bout in the heat was only 2.7% lower than in the neutral environment before reducing sharply in a linear fashion

Fig 5. Percentage of maximum heart rate for each four minute exercise bout at 40 and 24 degrees Celsius.

during the remaining exercise bouts, cumulating in W/Kg during the last 4 minutes in the heat being 20% lower than in the neutral environment. Cardiovascular Reponses Cardiovascular load expressed as percentage of maximum heart rate increased in a linear fashion for each bout for all environmental conditions (figures 4 and 5), indicating an inability of the players to fully recover during the 2 minute rest periods. The highest cardiovascular strain was noted in heat during the 3rd and 4th bout, suggesting this environmental condition may provide the greatest cardiovascular load although the findings were not significantly different to those of hypoxia. Why is there a difference in power degradation profile between heat and hypoxia? The finding that power degradation profiles differ between heat and hypoxia may be explained by the time required for acute physiological adaptations to occur in response to a specific type of environmental stressor. The time course for the transport of atmospheric oxygen to the exercising muscle in trained athletes can have a time constant of less than 20 seconds (Wells et al., 2014). In a hypoxic environment, such a quick delivery of less oxygenated blood to the exercising muscles is likely to have an immediate impact on aerobic exercise performance. There will have to be a reduction in work

football medic & scientist rate to counter the reduced oxygen availability for oxidative respiration when the cardiovascular system is already working close to its maximal capability for a sustained period. In the current study, when oxygen saturation was recorded at the end of each 4 minute bout during exercise in the hypoxic environment (Figure 6), oxygen saturation was notably reduced within the first bout and only decreased marginally during the remainder of the session, correlating with the observed pattern of power degradation. In contrast, thermal stress can take a period of time to manifest itself, and not impose physiological adaptions above those normally expected during high-intensity exercise until there is a significant increase in core temperature (Gonzalez-Alonso et al., 1999). In our study, the measurement of tympanic temperature at the end of each exercise bout (Fig 7.) in the heat can be seen to progressively increase as the players struggle to maintain temperature, which would lead to greater vasodilation and redistribution of blood, contributing to reducing physical capability as the exercise challenged continued. Summary and Application of Findings These results show the average decrement in mean power output across four bouts of maximal-intensity cycling is similar in heat and hypoxia for a comparable or elevated cardiovascular response. However, the pattern of power degradation over the four sets was dependent upon the environmental condition, with power output impaired sooner in hypoxia compared to exercise in the heat where pronounced reductions in power output only occurred as exercise duration increased. Such profiles of power degradation would indicate that higher mechanical loads are achieved during initial stages of exercise in heat to that of hypoxia and are comparable to those performed in neutral conditions. Therefore, science / medical practitioners should consider the reason for reducing mechanical load and then select the most appropriate environmental stressor. The use of heat may have negative implications for severely load comprised players as they are exposed to higher than desirable mechanical stress during the initial stages of exercise whereas hypoxia appears to help safeguard against such an occurrence. In contrast, the more robust player who would benefit from some exposure to higher load may gain more benefit from exercising in the heat to permit higher work outputs but not for the entire session. Additionally, for the player nearing return to performance, repeated exposure to exercise in the heat may act as an ergogenic aid to enhance endurance capabilities in a shorter period of time than can be achieved in hypoxia (Sunderland et al., 2008).

Fig 6. Oxygen saturation in a control condition (C1) and across four exercise bouts when exercising in hypoxia at 13.5% atmospheric oxygen.

Fig 7. Tympanic temperature in a control condition (C1) and across the four exercise bouts when exercising at 40 degrees Celsius.

REFERENCES Garrett AT, Creasy R, Rehrer NJ, Patterson MJ, Cotter JD (2012) Effectiveness of short-term heat acclimation for highly trained athletes. Eur J Appl Physiol,112(5):1827-37. Goods et al., 2014 Gonzรกlez-Alonso J, Teller C, Andersen SL, Jensen FB, Hyldig T, Nielsen B (1999) Influence of body temperature on the development of fatigue during prolonged exercise in the heat. J Appl Physiol 86(3):10329. Jubeau M, Rupp T, Temesi J, Perrey S, Wuyam B, Millet GY, Verges S (2016) Neuromuscular Fatigue during Prolonged Exercise in Hypoxia. Med Sci Sports Exerc. 6. [Epub ahead of print] Mackenzie et al., 2016 Mackenzie, B., Wells, C., (2016) Differences in power output profiles during high-intensity intermittent cycling in acute heat and hypoxic exposure. Journal of Sports Sciences, 34: 180 - 181 Sunderland C, Morris JG, Nevill ME (2008) A heat acclimation protocol for team sports. Br J Sports Med, (5):327-33. Paralikar, S and Paralikar, J (2010) High Altitude Medicine. Indian Journal of Occupational Medicine, 14 (1), 6-12 Vogt M, Hoppeler H (2010) Is hypoxia training good for muscles and exercise performance? Prog Cardiovasc Dis, 52(6):525-33. Wells C, Edwards A, Fysh M, Drust B (2014) Effects of high-intensity running training on soccer-specific fitness in professional male players. Appl Physiol Nutr Metab.39(7):763-9.

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Pictured: Southampton’s James Ward-Prowse looks in pain after picking up an ankle injury during the EFL Cup Semi Final in January.

THERE ARE MANY GOOD REASONS TO SCREEN YOUR ATHLETES BUT PREDICTING FUTURE INJURY IS NOT ONE OF THEM FEATURE/NICOL VAN DYK, ARNHILD BAKKEN, STEPHEN TARGETT AND ROALD BAHR, QATAR

ike is a physiotherapist working at a football club. Before the start of each season, the medical team does their planning for the year. An important part of this planning will be the periodic health evaluation (PHE), which is commonly referred to as the ‘screening exam’. Like many football clubs worldwide, they complete a comprehensive precompetition musculoskeletal screening consisting of a questionnaire, functional testing and isokinetic strength testing of the lower extremity1. There are multiple goals of these screening tests. In Mike’s and many other physiotherapists’ mind, one major goal is establishing which players are at risk of injury and providing potential interventions that could reduce the risk. In occupational health and safety these kinds of screening tests are commonplace2. It is believed that

identifying risk factors will allow for a suitable intervention to be put in place that might reduce the risk of injuries or better yet, prevent injuries altogether. There is, however, debatable evidence for the effect of these practices on general health and mortality rates. Nonetheless, interventions to promote safety and reduce the risk of injury/illness in the workplace are now routine. Not long ago there were no restrictions on smoking in the workplace and ashtrays were a normal part of office equipment. Today, it is hard to imagine any institution that would still allow their employees to smoke inside the office. Another example might be providing protection against head injuries at a construction site. It is now mandatory that all workers (not just those doing high-risk activities) wear protective head gear and it would be unthinkable that any worker (or visitor) to a construction

site would not be issued a hard hat. In sports medicine, one of the goals of the PHE is to identify potential risk factors for injury and illness. It is important for sporting authorities to protect the health of the athlete, since professional sport is well-known for high risk of injury, illness, and the possible development of longterm health concerns. Organisations such as the International Olympic Committee (IOC) and FIFA have released guidelines on the PHE for athletes, attempting to set a standard for effective testing that would assist in early detection of cardiovascular and other potential health (medical) risks4,5. In fact, at Mike’s club, they follow the FIFA guidelines and use the FIFA precompetition medical assessment as a template for their PHE5. This consists of a comprehensive cardiovascular examination, general medical

football medic & scientist

Pictured: Watford goalkeeper Costel Pantilimon reacts to an injury during the Emirates FA Cup, Fourth Round match against Millwall at The Den.

evaluation (including blood tests) and musculoskeletal assessment to be performed on all players. The value of musculoskeletal testing and which are the best tests to be performed is often debated and consequently the exact makeup of the musculoskeletal assessment varies from club to club. Mike is particularly interested in isokinetic strength testing (Figure 1), which forms part of the testing battery for most teams since decreased strength has been shown to be a risk factor for hamstring injuries6,7. After the pre-season screening isokinetic strength assessment has been performed under his supervision, 10 of the players in Mike’s squad are identified with a lower hamstring eccentric strength compared to the rest of the team, according to cut off points suggested in the literature as a high risk of injury7. Like many others, Mike is making the seemingly logical conclusion: These specific players have an increased risk of an injury if they continue playing and we need to target them with a specific strength training programme. Would you agree? Now let’s see how Mike has been tricked and why this statement is wrong. IDENTIFYING RISK FACTORS WILL NOT IDENTIFY THE ATHLETES AT RISK Hamstring injuries are common in sport and many studies have investigated the use of isokinetic testing to establish whether the strength of the quadriceps and hamstring muscles could be identified as risk factors for hamstring

injury7,8,9,10. A recent meta-analysis identified age, previous injury and increased quadriceps strength as risk factors for hamstring injuries11. Although not supported by the meta-analysis, decreased eccentric hamstring strength has also been identified by several small prospective and retrospective studies as a risk factor for hamstring injury. However, Bahr and Holme have shown 200 injured subjects are needed to identify small to moderate associations with injury risk12. To overcome previous limitations of small sample sizes and low numbers of injuries van Dyk et al13 recently performed a study which included 614 subjects and 190 injuries. They found significant association between decreased eccentric hamstring strength (when normalised to body mass) and increased risk of hamstring injury (odds ratio 1.37 per 1 Nm/kg difference in strength). So case closed, right? It seems clear that there is an association between low hamstring eccentric strength and hamstring injury, that is until we look at the big picture, when it becomes evident we are being fooled by the group effect. To clarify, let’s use smoking as an example. A clear association between smoking and all-cause mortality, in particular lung cancer and cardiovascular disease, has been well established for more than 20 years14. The burden of this health risk on the health system was clearly substantial, therefore it did not take long (although many will argue much too long) to recommend a simple intervention strategy – quit smoking. This was supported by the evidence of a strong group effect.

The group with a history of smoking has a significantly increased risk of developing cancer and cardiovascular disease compared to non-smokers. The message is clear – those who smoke are at higher risk than those who don’t. A common mistake is to assume that what is true for the group is also true for the individual – it is not. You might never smoke in your life but develop any one of these conditions or you might smoke 20 cigarettes a day and never develop lung or cardiovascular disease. Why is this? Because identifying a group effect, even one as strong as this, does not tell us anything about individual risk. This is how the evidence has tricked Mike as well. In Figure 2, the distribution of eccentric hamstring strength in the injured (red) and uninjured players (gold) are shown. Firstly, it is clear that the data from the injured players and the uninjured players overlap each other and that it would be impossible to accurately differentiate one group from the other using these measurements. Secondly, Mike knows that this level of difference may actually be due to the inherent variability in the hamstring eccentric strength measurements and not due to any true difference between individuals. A minimal detectable change (MDC) usually indicates how much a test score needs to change to know whether it represents a real and meaningful difference. The absolute difference in strength between the injured and uninjured group was only 7.2 Nm13. For this isokinetic strength test, the MDC was 73.7 Nm. That is ten times more than the absolute difference

reported and clinically does not help to distinguish which players will get injured. So an isokinetic hamstrings strength test is not sensitive or specific enough that we can establish a clear cut off line that would indicate which players in Mike’s team are safe from injury and which players should improve their eccentric hamstring strength to hopefully reduce the risk of injury. Receiver operating characteristics curve analyses are often used in tests such as these to determine the sensitivity (true positives: if the test identifies you will get a hamstring injury and you do) and specificity (true negatives: if the test says you are safe and will not get injury and you don’t). In this example, receiver operating characteristics curve analyses revealed an area under the curve of 0.56. A value of 1.0 indicates perfect prediction and 0.5 indicates a useless test (one no better at identifying true positives than flipping a coin). So in this case is seems as though you might as well flip a coin rather than look at eccentric hamstring strength to predict who will get injured. Could the odds ratio (OR) instead be useful to Mike? An OR is a statistical measure to quantify how strongly a factor, (in this case isokinetic strength) is associated with a particular outcome, (sustaining a hamstring injury). A recent infographic in the British Journal of Sports Medicine explains how to calculate the likelihood ratio of sustaining an injury from the odds15. With this study by van Dyk et al, an OR of 1.37 was reported. This implies that players with decreased eccentric hamstring strength have a 37% greater chance of hamstring injury. That seems like a rather large increase in risk. But what if we consider the base rate? The base rate represents the chance of a

Pictured: Tottenham Hotspur’s Harry Kane leaves the field after suffering an injury during an FA Cup Quarter Final in March.

hamstring injury for anyone in the squad, regardless of any other factors. In football, it is reported as 1 in every 9 players – so the chance of a hamstring injury is about 11%. If we use the OR of 1.37 seen in this study and calculate the risk on top of the base rate with the likelihood ratio of 37%, it increases the chance to 14%. So using the OR helps Mike to understand that the players with decreased hamstring strength have a predicted injury risk of 14% compared with 11% for the whole squad. What about other risk factors which reports much larger odds ratios? Another high-profile risk factor finding has been

Pictured: West Ham United’s Mark Noble leaves the pitch after picking up an injury during a Premier League match in January.

knee abduction in the drop jump test for anterior cruciate ligament (ACL) injury. Although incidence varies across different populations, it is commonly reported as 1 to 6%16. So let’s assume a risk for ACL injury of about 6%. An OR of 2.3 is reported for lateral knee displacement (abduction) and ACL injury17, which then changes the risk for the player from 6% to 12.5%. This means that there is still an 87.5% chance that the players ‘at risk’ of ACL injury will not sustain one. Such differences are too small to make any strong recommendations regarding individual players based purely on the results of such tests and needs to be interpreted for each player on an individual basis. A statistically significant association between the injured group and a specific risk factor clearly indicates that there may be a causal relationship between a specific test result and injury risk. These findings are important to improve and grow our understanding of how and why these injuries develop, but it still does not help Mike. This is not sufficient to use the test to predict who is at risk and who is not, or to identify the individual player who will go on to have an injury this season18. Not at all. THEN WHAT ARE THE REASONS FOR SCREENING, IF WE CAN’T INDENTIFY THE PLAYERS WHO WILL GET INJURED? There are numerous good reasons why Mike would want to continue screening his athletes. As outlined in the IOC consensus statement on PHE of elite athletes, it provides an opportunity to detect current musculoskeletal symptoms/ issues which may influence the athlete’s ability to train and compete4. A recent

football medic & scientist study of PHE examinations at Aspetar examined the findings of targeted musculoskeletal examination based on careful history. In the 558 professional football players included more than a third had a musculoskeletal condition requiring follow-up in the form of prevention intervention or treatment. (Figure 3)19. Detecting current musculoskeletal conditions In Mike’s squad of 30 players, he would have identified at least 10 players who might require some form of intervention or treatment. This might be as simple as reassuring a player regarding an ongoing injury or physical symptoms or the introduction of a treatment programme that is targeting the whole team. Establish performance baseline and healthy state Another good reason to conduct PHE is to establish a performance baseline for the athlete in the healthy state. For example, if one of Mike’s players sustains an ACL or hamstring injury during the season, the isokinetic strength test or functional tests performed during screening represents an accurate reference point for the clinician to determine rehabilitation response/success and can assist in return to play decisionmaking. Alternatively, if the club decides to add a specific training/strengthening programme during the season, a baseline reference point might assist the team to establish whether or not such a programme has been successful. Building the clinician-athlete relationship Another potential benefit of conducting regular a PHE is establishing or building a relationship between the athlete and

Pictured: Everton’s Morgan Schneiderlin receives treatment during a Premier League match against Hull City in March.

the health personnel, which can positively influence the care of the player. It is also an opportunity to provide education regarding certain policies or injury prevention strategies and to receive both subjective and objective feedback from the players on their current health status. Furthermore, a review of medications and supplements can be undertaken to avoid inadvertent doping20. In some settings, a PHE might be necessary to satisfy the medico-legal duties of care, for example a mandated medical assessment as part of a tournament.

CLINICAL IMPLICATIONS Group effects are commonly misinterpreted as individual risk and incorrectly used to make injury prediction for individual athletes. It is important to understand that identifying isolated risk factors or even their interactions with other risk factors, does not enable you to predict which individuals will go on to have an injury. We often want to simplify results when determining injury risk, but this is not the true picture. To illustrate the point in a different way, we present two ways in which Mike can think about when interpreting the test results: Reasoning 1: ~ 3TRaTPbTS TRRT]caXR WP\bcaX]V bcaT]VcW , risk factor for injury ~ 9^W]]h , 3TRaTPbTS TRRT]caXR WP\bcaX]V strength therefore ~ 9^W]]h fX[[ VTc X]YdaTS OR

Pictured: Crystal Palace’s Jeffrey Schlupp picks up a hamstring injury whilst playing for the club in January 2017.

Reasoning 2: ~ 3TRaTPbTS TRRT]caXR WP\bcaX]V bcaT]VcW , risk factor for injury (at group level) ~ 9^W]]h , 3TRaTPbTS TRRT]caXR WP\bcaX]V strength (at individual level), therefore ~ 0[cW^dVW 9^W]]h WPb STRaTPbTS TRRT]caXR hamstring strength that is associated with an increased risk of injury, he may not have an injury (and someone with normal hamstring strength may have an injury). But since Johnny is part of the group and the risk of the whole group is increased by having decreased eccentric hamstring strength, it is worthwhile improving the hamstring strength of the whole squad

as some hamstring injuries will also occur in those with normal hamstring strength. Johnny might still have an injury, but we can improve his odds. It is not strange that Reasoning 1 is appealing, mainly because it is easy to follow and requires relatively little cognitive effort. The correct approach is, of course, shown in Reasoning 2. The difficulty comes in understanding the statistical process and what the results really mean. Mike now understands that identifying an isolated risk factor in a specific group cannot identify the individual players who will sustain an injury. So when reading results where statistical significance ORs, likelihood ratios and cut-off values are reported, it is also important to look for the distribution of the players in these studies, the effect size or even the absolute difference to understand the clinical value. Mike will not be tricked again and neither should you. We would not recommend that you suspend all musculoskeletal screening at the club since a PHE has other benefits (Table 1) such as allowing for the early detection of musculoskeletal issues, measurement of baseline values and building relationships between medical staff and players. If approached with these goals in mind the PHE or annual pre-season screening should remain a part

of the pre-season preparations for every team. Identifying risk factors is a vital step in the process of understanding how we can improve our injury prevention efforts. Although we cannot identify athletes on an individual basis, we can implement group interventions aimed at reducing the risk for an entire team or group of players. As injury prevention research continues to grow and mature, it moves us closer to protecting the health of our athletes and ensuring the safe participation in sport. CONCLUSION Risk factor identification is valuable in growing our understanding of specific injuries and which factors may be important for how they happen, but it does not allow for a simple, direct translation to injury prediction. However, PHE is a valuable tool that allows the clinician to monitor, engage and manage the musculoskeletal health of the athlete in a meaningful way. Nicol van Dyk M.Sc. Phys. (OMT), B.Sc. Physiotherapist Rehabilitation Department Aspetar – Orthopaedic and Sports Medicine Hospital Doha, Qatar Contact: nicol.vandyk@aspetar.com

Arnhild Bakken P.T., M.Sc. Phys. Postgraduate Researcher Department of Sports Medicine Norwegian School of Sport Sciences Oslo Sports Trauma Research Center Oslo, Norway Aspetar Sports Injury & Illness Prevention Programme Aspetar – Orthopaedic and Sports Medicine Hospital Doha, Qatar Stephen Targett M.B.Ch.B., F.A.S.C.P Sports Medicine Physician Aspetar – Orthopaedic and Sports Medicine Hospital Doha, Qatar Roald Bahr M.D., Ph.D. Head of Aspetar Sports Injury & Illness Prevention Programme Aspetar – Orthopaedic and Sports Medicine Hospital Doha, Qatar Professor & Chair Department of Sports Medicine Norwegian School of Sport Sciences Oslo Sports Trauma Research Center Oslo, Norway

REFERENCES 1. Gouttebarge V, Sluiter JK. Medical examinations undertaken by Dutch professional football clubs. Occup Med 2014; 64:13-16. 2. Krogsboll LT, Jorgensen KJ, Gronhoj Larsen C, Gotzsche PC. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ 2012; 345:e7191. 3. Farrelly MC, Evans WN, Sfekas AE. The impact of workplace smoking bans: results from a national survey. Tob Control 1999; 8:272-277. 4. Ljungqvist A, Jenoure P, Engebretsen L, Alonso JM, Bahr R, Clough A et al. The International Olympic Committee (IOC) Consensus Statement on periodic health evaluation of elite athletes March 2009. Br J Sports Med 2009; 43:631-643. 5. Dvorak J, Grimm K, Schmied C, Junge A. Development and implementation of a standardized precompetition medical assessment of international elite football players 2006 FIFA World Cup Germany. Clin J Sport Med 2009; 19:316-321. 6. Foreman TK, Addy T, Baker S, Burns J, Hill N, Madden T. Prospective studies into the causation of hamstring injuries in sport: A systematic review. Phys Ther Sport 2006; 7:101-109. 7. Croisier J-L, Ganteaume S, Binet J, Genty M, Ferret J-M. Strength imbalances and prevention of hamstring injury in professional soccer players: a prospective study. Am J Sports Med 2008; 36:1469-1475. 8. Tol JL, Hamilton B, Eirale C, Muxart P, Jacobsen P, Whiteley R. At return to play following hamstring injury the majority of professional football players have residual isokinetic deficits. Br J Sports Med 2014; 48:1364-1369. 9. Askling C. Type of acute hamstring strain affects flexibility, strength, and time to return to pre-injury level. Br J Sports Med 2006; 40:4044. 10. Eirale C, Tol JL, Farooq A, Smiley F, Chalabi H. Low injury rate strongly correlates with team success in Qatari professional football. Br J Sports Med 2013; 47:807-808. 11. Freckleton G, Pizzari T. Risk factors for hamstring muscle strain injury in sport: a systematic review and meta-analysis. Br J Sports Med 2013; 47:351-358. 12. Bahr R, Holme I. Risk factors for sports injuries -- a methodological approach. Br J Sports Med 2003; 37:384-392. 13. van Dyk N, Bahr R, Whiteley R, Tol JL, Kumar BD, Hamilton B et al. Hamstring and quadriceps isokinetic strength deficits are weak risk factors for hamstring strain injuries: a 4-year cohort study. Am J Sports Med 2016; 44:1789-1795. 14. Blair SN, Kampert JB, Kohl HW 3rd, Barlow CE, Macera CA, Paffenbarger RS et al. Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause mortality in men and women. JAMA 1996; 276:205-210. 15. Whiteley R. Screening and likelihood ratio infographic. Br J Sports Med 2016; 50:837-838. 16. Waldén M, Hägglund M, Werner J, Ekstrand J. The epidemiology of anterior cruciate ligament injury in football (soccer): a review of the literature from a gender-related perspective. Knee Surg Sports Traumatol Arthrosc 2011; 19:3-10. 17. Zazulak BT, Hewett TE, Reeves NP, Goldberg B, Cholewicki J. Deficits in neuromuscular control of the trunk predict knee injury risk: a prospective biomechanical-epidemiologic study. Am J Sports Med 2007; 35:1123-1130. 18. Bahr R. Why screening tests to predict injury do not work and probably never will…: a critical review. Br J Sports Med 2016; 50:776-780. 19. Bakken A, Targett S, Bere T, Adamuz M-C, Tol JL, Whiteley R et al. Health conditions detected in a comprehensive periodic health evaluation of 558 professional football players. Br J Sports Med 2016; 50:1142-1150. 20. Dijkstra HP, Pollock N, Chakraverty R, Alonso JM. Managing the health of the elite athlete: a new integrated performance health management and coaching model. Br J Sports Med 2014; 48:523-531. This article was originally published in the Aspetar Sports Medicine Journal, available from www.aspetar.com/journal. All copyright is property of Aspetar and may not be reproduced without permission.

Hard to Break

Building resilience in modern day athletes

27TH/28TH MAY FA CUP FINAL WEEKEND RADISSON BLU HOTEL EAST MIDLANDS DE74 2TZ FOR MORE DETAILS TEL: 0333 4567897 E-MAIL: ADMIN@FOOTBALLMEDIC.CO.UK TWITTER: @FOOTBALLMEDSCI FACEBOOK: @FOOTBALLMEDICALASSOCIATION INSTAGRAM: FOOTBALLMEDICALASSOCIATION

FMA FOOTBALL MEDICAL ASSOCIATION

CONFERENCE

& AWARDS

2017

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FMA CONFERENCE PROGRAMME 2017 ‘HARD TO BREAK’ BUILDING RESILIENCE IN MODERN-DAY ATHLETES SATURDAY 27 TH MAY 2017 10.00

Registration Opens

Please sign in and collect your delegate pack

12.00

Opening Address

Eamonn Salmon Chief Executive Officer Football Medical Association

Session 1

THE FIVE STEPS TO A WINNING MINDSET

12.15

Key Note Presentation

Professor Damian Hughes Professor of Organisational Psychology and Change Manchester Metropolitan University

Session 2 BUILDING RESILIENCE IN MODERN-DAY ATHLETES A STRENGTH & CONDITIONING AND A REHABILITATION PERSPECTIVE ‘Physical Robustness’, ‘Grit’, and ‘Resiliency’ are words and phrases most spoken about by practitioners, and everyone wants to know how to get more of ‘it’! Today, more than ever, key stakeholders recognize that one of the key factors for success (or failure) of their season is the ability (or inability) of their athletes to be resilient. The younger generations of athletes are growing up in a time where we have a much higher standard of living then previous generations. In their everyday life, resiliency as a skill, is not often being called upon and therefore underdeveloped. Are we expecting too much for our athletes to ‘arrive’ at our programs with strong resiliency skills already developed? Sport requires athletes to bounce back from setbacks immediately. This session will explore the fundamentals of what resilience is, how resilient athletes behave, the stages of coping and recovery from setbacks, and the key strategies for building resilience. 13.00

Building Resilience Through Applied Strength & Conditioning

Dr. Ben Rosenblatt Lead Men’s Physical Performance Coach, The F.A.

13.30

Building Resilience in The Rehabilitation Process

John Kiely Senior Lecturer in Elite Performance UCLAN

14.00

TRADE EXHIBITION & COFFEE BREAK

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Session 3 Sponsored by the FA BUILDING RESILIENCE IN MODERN-DAY ATHLETES – A MULTI-DISCIPLINARY APPROACH

14.45

A Medical Perspective

Dr. Mark Gillett Director of Performance West Bromwich Albion FC

15.00

A Psychiatrist’s Perspective Growth Mindset and Building Resilience

Dr Jag Basra Doctor of Psychiatry

football medic & scientist

27 - 28TH MAY 2016 RADISSON BLU EAST MIDLANDS AIRPORT 15.15

A Sports Science Perspective

15.30

Q&A

Dr Carl Wells Sport Science Lead Perform

Session 4 Sponsored by Renew Health Ltd FROM DATA TO PERFORMANCE – IS IT WORKING? ‘Physical Robustness’, ‘Grit’, and ‘Resiliency’ are words and phrases most spoken about by practitioners, and everyone wants to know how to get more of ‘it’! Today, more than ever, key stakeholders recognize that one of the key factors for success (or failure) of their season is the ability (or inability) of their athletes to be resilient. The younger generations of athletes are growing up in a time where we have a much higher standard of living then previous generations. In their everyday life, resiliency as a skill, is not often being called upon and therefore underdeveloped. Are we expecting too much for our athletes to ‘arrive’ at our programs with strong resiliency skills already developed? Sport requires athletes to bounce back from setbacks immediately. This session will explore the fundamentals of what resilience is, how resilient athletes behave, the stages of coping and recovery from setbacks, and the key strategies for building resilience. 15.45

The Future of Data and Performance

Michael Clarkson Catapult Sports

16.00

Are We Creating a Soft Generation?

Robin Thorpe Sport Scientist Manchester United FC

16.15

A Sports Science Perspective

Blake Wooster CEO 21st Club

15.30

Q&A

SUNDAY 28TH MAY 2017 9.00

TRADE EXHIBITION

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Session 5

PHYSICAL PREPARATION & SKILL DEVELOPMENT, THE GYMNASTICS WAY 9.30

Keynote Presentation

10.00

Q&A

10.15

TRADE EXHIBITION & COFFEE BREAK

Nick Ruddock Performance Gymnastics Coach

Please support our exhibitors, partners and sponsors

Session 6 Sponsored by BSN Medical Ltd In this session, a professional game coach/manager will be interviewed by The FA Performance Education Team as to how they utilise the multidisciplinary teams available to them and how they use these resources to achieve winning results. The team will focus on questions around the coach’s values and beliefs, the environment they try to create, their approach to making players fit to perform repeatedly and their consideration for future player development. Questions around developing and maintaining robustness will also be fielded and there will be an opportunity for questions from the audience.

10.45

A professional Manager/Coach in conversation with the FA’s Performance & Medical Education Team

Performance Education Team: Justyn Price Lead Joce Brooks Psychology Lisa Hodgson Medical Matt Portas Physical Performance Shall Hall Performance Analysis David Court Talent ID

Session 7 Sponsored by The FA FUTURE PHYSIOTHERAPISTS, DOCTORS, SCIENCE PRACTITIONERS & SPORTS THERAPISTS IN FOOTBALL. WHAT SHOULD THEIR PROFILE BE? This session will discuss and debate what should be the profile of the physiotherapist, doctor and scientist in football. Should the practitioner be multi-skilled with extensive knowledge of each other’s work or should they work in intellectual silos? Should there be more collective responsibility and sharing of success and failure? Are there examples of “better” practice of ways of working? What are the medico legal consequences of working outside are own professional remit? As service delivery providers, how do we increase our level of expertise and not be guilty of just practicing the way we have done for the last 10 years. What is best for the Club as compared to what is best for the practitioner or are these one and the same? Does the physiotherapist need to get back to the basics of remedial work and classic effective rehabilitation and prevention pathways rather than mini managing areas outside that of physiotherapy? If so how? Does the scientist need to step away from being a fitness assistant or a GPS guru and get more embedded in local academia? If so how? Should we all be able to cross over one another so in times of leave that we have a unit that continues to function? Should we now enforce the specialty of football medicine rather than the generic and vague ‘sport and exercise medicine’? What is the practitioner of the future?

11.45

A Physiotherapist Perspective

11.55

A Doctor’s Perspective

12.05

A Sport Science Perspective

12.15

A Sports Therapist Perspective

Chris Morgan Head Physiotherapist Crystal Palace FC Dr Richard Higgins Club Doctor, Sheffield Wednesday FC Medical Advisor to the EFL Richard Evans Head of Team & Individual Fitness Royal Belgian Football Association Ben Thompson Performance Therapist Manchester City FC

football medic & scientist

12.30

Q&A

12.45

Closing Address

Eamonn Salmon Chief Executive Football Medical Association

Join us for the FOOTBALL MEDICAL ASSOCIATION AWARDS 2017 Saturday 27th May 16.45

FA CUP FINAL Bar Available

Donnington Suite

19.30

DRINKS RECEPTION Kindly sponsored by

Conference Lobby

20.00

AWARDS DINNER Welcome to our 4th Annual Awards Dinner

Wheatcroft Suite

With thanks to our exhibitors & sponsors 2017

Introducing the Presenters

Professor Damian Hirst Professor of Organisational Psychology & Change Manchester Metropolitan University

John Kiely Senior Lecturer in Elite Performance UCLAN

Nick Ruddock Performance Gymnastics Coach

Mark Gillett Director of Performance West Bromwich Albion FC

Jag Basra Doctor of Psychiatry

Dr Carl Wells Sport Science Lead Perform

Dr Ben Rosenblatt Lead Menâ&#x20AC;&#x2122;s Physical Performance Coach, The F.A.

Robin Thorpe Sport Scientist Manchester United FC

Dr Richard Higgins Club Doctor, Sheffield Wednesday FC Medical Advisor to the EFL

Chris Morgan Head Physiotherapist Crystal Palace FC

Richard Evans Head of Team & Individual Fitness Royal Belgian Football Association

Ben Thompson Performance Therapist Manchester City FC

Plus speakers from the Performance Education Team at the FA Justyn Price Performance Education Lead Matt Portas Physical Performance

Joce Brooks Psychology Shall Hall Performance Analyst

Lisa Hodgson Medical David Court Talent ID

football medic & scientist

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A TEAM OF STRATEGIC WEB DESIGNERS & DIGITAL MARKETING SPECIALISTS DELIVERING BUSINESS GROWTH ADVERT/ DEVELOPING A NEW WEBSITE FOR THE FOOTBALL MEDICAL ASSOCIATION

fter working with Red-Fern Media for over 7 years, the Football Medical Association were going through a substantial growth period due to some highprofile legal cases with medical professionals within the football Premier League and other leagues in the UK. With worldwide TV coverage, Eamon Salmon, CEO at the football medical association, was aware that their existing website needed to be re-developed. The brief was to develop a digital strategy that would see the workflows, user experience, design and administration area move to the next level to take their business forward and continue the growth.

The design and development teams at RedFern Media took a strategic approach to the delivery of the project, developing site maps and user flows before any design orcoding had even started. With a strategy in place, the design team were able to create stunning, well-structured designs and layouts, specific call-to-actions to prompt potential customers and existing customers to the correct pages, increasing engagement, and lead generation. The development team worked through the night to develop optimised workflows and structured code to deliver a fast, fullyoptimised working content management system. With a bespoke member registration process, football medicine register and forum platform, the site is now equipped for the continued growth of the Football Medical Association.

“

The FMA now has one of the most engaging and interactive websites in professional sport. This will not only generate interest but will promote medicine and science as major contributors within our industry.”

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FMA REGISTER CONNECTING WORLD LEADING MEDICAL AND SCIENCE EXPERTISE WITHIN THE GAME, WITH FAN BASES AND GRASSROOTS FOOTBALL

An elite register of medical and science practitioners who have experience and expertise in the professional football arena. The FMA Register is the perfect platform for members to highlight and promote their skills and expertise to colleagues within the game, fan bases and grassroots football. As an elite register listing the FMA Register is not open to any practitioner. Registrants must have worked in a professional capacity with players or a club in the top 5 tiers in English football, the top 2 tiers in Scotland or the FA WSL1. Eligible practitioners include doctor, physiotherapists, sports therapist, optometrist, nutritionist, soft tissue therapist, sports psychologist, podiatrist, osteopath, chiropractor, consultant surgeon, consultant physician, sports rehabilitator. “The FMA website reaches on average 11,000 unique users weekly, which is a terrific audience to engage with. We are busy promoting the FMA Register even further, with the help of 100,000’s of contacts through various associations within the game and company databases”.

“

This is a brilliant project that will put us in touch personally with fans and grassroots football. Having been involved in Private Practice alongside Football for many years, I am convinced that this will be a resounding success. This is a great initiative.’ Derek Wright - Head Physiotherapist Newcastle United FC

football medic & scientist

“We have received an incredible response so far and this is a remarkable initiative that will allow grassroots players to access personnel who are a part of their local football team and who treat their favourite player! At the same time this will help keep people healthy and playing the game for longer! “ adds Angela. The first stage of the register is now well underway and has already created a huge amount of interest both within and beyond the football industry. Practitioners have been keen to join and update their profile on the register with over 200 new entries within the first month clearly this has been a hit! The second phase, to invite health care providers to join the register, is also underway and should see a swathe of members from this sector in the coming weeks. You can keep up to date with all the developments, which are highlighted almost daily on our Register Latest News page, found on our website www.footballmedic.co.uk. The Register is proving to be an attractive medium for those in practice to highlight

“

I work in the professional game and see patients in my Clinic as well. Fans who come to see me love to talk about the Club as it’s the life blood of our community. This Register will open up the same opportunity for fans and practitioners across the country’. Dave Tinker - Podiatrist Burnley Football Club, Private Practitioner

their clinics, services and personal profile and promote their skills to potential clients which has never been easier to access. Colleagues currently working within the game are already using this register as a resource to find practitioners either with specialisms they are in need of or to cover absence or address staffing levels while appointments are pending. In addition, practitioners can further promote their clinical specialty by submitting articles of interest for our quarterly magazine ‘Football Medic &

Taking up private practice is the natural progression for most of us as we leave the game. We genuinely do want to give something back to football and working with the register and at grassroots level gives us the perfect opportunity’. Alan Smith - Head Physiotherapist Aston Villa FC

Scientist’ or as a contribution to our CPD programme. If you are eligible to join the register and would like to know more, please go to our website www.footballmedic.co.uk/ fmaregister or call me on 07432 360789 or 0333 4567897.

FMA`s newest member of staff Angela Walton reflects on her role within the association. “Having joined the Football Medical Association (FMA) in January, I feel very privileged to be a part of such a fantastic association which serves to improve standards throughout medicine and science in professional football. In taking up the post of project lead I have already witnessed huge support for this initiative, with new and existing members joining daily.”

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Pictured: The finished cryotherapy chamber.

AFC BOURNEMOUTH

A PRACTICAL APPLICATION OF WHOLE BODY CRYOTHERAPY FEATURE/CRYOACTION Having sampled cryotherapy at a Dubai training camp, the AFC Bournemouth medical team decided to implement the treatment as part of the players’ recovery protocols.

he team already has a strong recovery programme in place and cryotherapy was seen to enhance and extend the offering to the players The aim was to reduce the impact of the intensive Premier League match schedule and the frenetic pace of the English game. Cryotherapy was seen to offer an additional modality in the club’s regimen, aiming to keep the players, healthy and injury- free as well as enhancing their overall well being.. A suitable site was identified within the training complex in the former doctor’s room. CryoAction were appointed and designed a bespoke cryotherapy unit to make maximum use of the available space. The engineering team were under a tight timeline to ensure the unit’s readiness for the season to come. The installation was completed in a total of 10 days and involved teams from 4 companies working together to install the

cryotherapy chamber, the gas vessel and pipework. CryoAction staff project managed the process on site from start to finish. Graeme Toogood, AFC Bournemouth’s operation manager commented on the installation. “CryoAction were an ideal contractor, and one of the best we have ever had at the club. Everything was meticulously planned for during each stage of the installation, ranging from our fully documented responsibilities prior to their arrival on site, through to the completion of the project on time and with minimal disruption.” The medical and sports science teams were instructed in the use of the equipment with a comprehensive user training day and the first sessions were delivered to first team players with CryoAction staff on hand. Now some time has elapsed since the installation. How has the whole body cryotherapy chamber been adopted by the club?

Pictured: Medical room prior to work commencing.

Pictured: Work in progress.

football medic & scientist Steve Hand, AFC Bournemouth’s physiotherapist commented “We had the cryotherapy chamber installed pre-season and we use the cryotherapy chamber regularly, after training. We have a slot where all players will go through the chamber.” The facility is fully integrated into recovery protocols post-game and after each training session. How have the players reacted?. ‘The feedback from players has been very good with a number of regulars.” Steve added, ”As you can imagine there were a few who were sceptical of entering a room at -135°C but the majority of the squad will go in and they like it.” The players undergo a 3½ minute treatment. The first is a 30 second session in a pre-chamber, cooled to -60°C, followed by 3 minutes in the main chamber at -135°C.. The chamber is used after training and post game, even if the team is playing and away game. Steve explains “If we are at home, after the game and the manager’s talk, the players will have a massage and recovery and then enter the cryotherapy before going home. Similarly for an away game, the players will return to the training centre and go through the cryochamber before heading home” An interesting application area that Steve and the team are looking at is to address the case of players, particularly after an evening game, having high adrenaline levels and there is a case for cryotherapy alleviating this detrimental factor and helping the players reduce their stress levels, improve their overall wellbeing and enhance their sleep quality. For injured players, the use of the cryotherapy chamber is compulsory. Steve explains, “The cryotherapy chamber is open for a for an hour after training and we tailor this time for the injured players. They will have a morning session and join the rest of the squad, post-training. Have a cryotherapy treatment before lunch and then come back for their second session.” Despite the club having ice-baths, the injured players cryotherapy treatment is seen as offering additional benefits such hormonal and anti-inflammatory aspects. As Steve pointed out, “Its another modality that we can use to help the injured players. Its not hard to do, its just 3 minutes of your time.” AFC Bournemouth are keen to explore and expand their use of cryotherapy. Steve commented, “We are collecting a lot of data from the players and will be conducting research into the benefits of the cryotherapy treatment, looking into player subjectives, comparing before we had cryotherapy and now to see the differences. We are looking into how it helps players with their fatigue, their recovery and helping their sleep. I am positive that there have been benefits from it.” Commenting on the installation, Steve said “CryoAction have delivered far more than we could have ever imagined. The

Pictured: Finished views of the cryotherapy chamber with a player undergoing treatment.

meetings that took place prior to buying were highly informative and transparent in terms of costs and expectations, the quality of the installation was superb, and the after care service is fantastic. I would have no hesitation in recommending CryoAction to any club.!”

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Pictured: Southampton Fans during their sideâ&#x20AC;&#x2122;s EFL Cup Final appearance versus Manchester United in February 2017.

FITNESS FOR FANS: PROFESSIONAL FOOTBALL AND PUBLIC HEALTH FEATURE/DR CHRISTOPHER BUNN, INSTITUTE OF HEALTH AND WELLBEING, UNIVERSITY OF GLASGOW, ON BEHALF OF BASEM/FSEM The benefits of an active life â&#x20AC;&#x201C; such as improved mental health and lowered risk of type 2 diabetes, heart disease and some cancers â&#x20AC;&#x201C; are well known amongst sports and exercise medicine professionals.

ut in the broader population, not everyone is able to realise these benefits. As part of this yearâ&#x20AC;&#x2122;s joint BASEM/FSEM conference in Liverpool, delegates had a lively discussion about how professional football (and other sporting) clubs can help to get the population moving more. The session began with Dr Justin Varney from Public Health England. Justin presented the current picture of physical activity levels in England drawn from â&#x20AC;&#x2DC;Everybody active, every dayâ&#x20AC;&#x2122;, which reported that: ~ "" Û \T] P]S #$ Û f^\T] PaT ]^c active enough for good health ~ ^][h ! Û Q^hb P]S % Û VXa[b PVTS 5-15 achieve recommended levels of physical activity

~ X]PRcXeXch [TeT[b PaT WXVWTbc X] RWX[SaT] X] the lowest economic group ~ fP[ZX]V caX_b STRaTPbTS Qh " QTcfTT] 1995 and 2013 ~ %# ^U caX_b PaT \PST Qh RPa !! PaT \PST on foot and 2% are made by bike He then set out a variety of ways in which the UK Government has committed to tackle the problems of inactive and sedentary lifestyles and pointed us all to â&#x20AC;&#x2DC;Sporting Futureâ&#x20AC;&#x2122;, which is the first new national strategy for sport in more than a decade. The strategy includes a commitment to invest in locally-delivered physical activity programs and is not just focussed on professional sport. Professional Football Clubâ&#x20AC;&#x2122;s Community Trusts and Foundations have known the power of their badge for a

long time. All over the UK they are already making a contribution to the fitness of the population. One significant contribution has come from Football Fans in Training (FFIT). FFIT is a weight loss and healthy living programme for overweight and obese men that was developed in Scotland by a team of academics led by the University of Glasgow, in collaboration with the Scottish Professional Football League Trust (SPFLT). FFIT is a 12-week programme delivered at the stadia of professional football clubs. The programme is informed by sociological understandings of masculinity and evidence on what works for behaviour change. As they attend each week participants are taught a range of new skills and techniques in a mixture of discussion-led learning and

football medic & scientist physical activity. Participants are also given a pedometer and pursue an evidence-based walking programme that starts with a baseline assessment and allows them to self-monitor their progress each week. FFIT was evaluated in a randomised controlled trial (RCT) funded by the National Institute for Health Research. The RCT found that 12 months from baseline, men who participated in FFIT lost an average of 4.94 kg more than those who had to wait 1 year before being offered the programme. Amongst the many other positive outcomes, FFIT participants also reported higher levels of physical activity than those on the waiting list. The findings from this study are very promising and have encouraged the Scottish Government to continue to fund the SPFLT to run FFIT in Scotland, where during the 2014/15 season, 1125 participated in the programme. Further afield, the SPFLT have been working with the Bundesliga in Germany, and have also trained clubs from the English leagues to deliver FFIT. Since developing FFIT, the team I am a member of at the University of Glasgow have begun to focus in more depth on how to help people improve their physical activity levels and reduce the time they spend being sedentary. Through a collaboration with academic colleagues in the Netherlands, Norway and Portugal, the European Healthy Stadia Network and PAL Technologies, we have developed European Fans in Training (EuroFIT). EuroFIT, like FFIT, is a 12-week programme designed to be delivered by professional football clubs at their stadia. It introduces a novel device (the SitFITTM) which provides real-time feedback on physical activity levels and time spent sedentary. The programme also incorporates an app-based game to encourage social support (‘MatchFIT’) and is grounded in a more extensive range of theory and evidence, drawn from across the EuroFIT

Pictured: Young Tottenham fans enjoy food ahead of the match at White Hart Lane versus Southampton in March 2017.

consortium . The EuroFIT programme is currently being evaluated in all four participating countries as part of a RCT. Once completed, the study will provide objective evidence of the programme’s impact on sedentary time and physical activity (as well as a range of secondary outcomes) and will deepen the knowledge and evidence base that is building for channelling health improvement efforts through football and other sporting clubs.

To finish where we began: the benefits of an active life. Taking a sustained walk can protect memory, reduce risk of stroke, diabetes and heart disease, improve mood, and prevent obesity. If we are to help others realise these benefits, we will need to follow the advice Dr. Andrew Murray gave our conference room in Liverpool: spread the word, think walking (and take action), work across sectors and be active ourselves. Football clubs can deliver on all four of these.

REFERENCES 1. Public Health England (2014). Everybody active, every day. London: Public Health England. 2. HM Government (2015). Sporting Future. London: HM Government 3.Hunt, K., Wyke, S., Gray, C.M. et al. (2014) A gender-sensitised weight loss and healthy living programme for overweight and obese men delivered by Scottish Premier League football clubs (FFIT): a pragmatic randomised controlled trial. The Lancet, 383, 9924, 1211–21. 4. Van Nassau, F. et al. (2016) Study protocol of European Fans in Training (EuroFIT): a four-country randomised controlled trial of a lifestyle program for men delivered in elite football clubs. BMC Public Health, 16, 598. Pictured: AFC Bournemouth fans make their way to the Vitality Stadium for their Premier League match against Swansea City.

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Pictured: Due to injury crisis Watfordâ&#x20AC;&#x2122;s Valon Behrami was rushed back to action against Stoke City in January. He unfortunately suffered a relapse of the injury and was removed at the half-time interval.

HAMSTRING INJURIES IN PROFESSIONAL FOOTBALL PLAYERS FEATURE/MR NICOLA ACAMPORA & DR KARL NEW A treatment model based on critical review of injury prevention, rehabilitation and return to play protocols. INTRODUCTION amstring muscle injuries (HMI) are the single most common football injury at elite levels and these injuries are associated with significant time loss (Ekstrand et al., 2011 ; Hagglund et al., 2009). According to Ekstrand et al. (2011) a professional team with 25 players could be expected to suffer about five HMI per season. Taking into account the rehabilitation process an estimation of 80-90 days of football could be lost throughout each season on hamstring injuries with the average injury causing the loss of three to four matches (Brukner and Khan, 2012). This along with the high risk of recurrence, said to be between 12-63%, can lead to disturbing effects both on economical and performance parameters for clubs and players involved (Petersen et al., 2010 ; Wood et al., 2004).

The main functions of the hamstring muscle group are hip extension and knee flexion. This bi-articulate function drastically increases the demands on the muscle when an individual is required to sprint because the hamstrings act eccentrically during the late swing and terminal stance phases of the running cycle with the greatest torques seen during the late swing to midstance phase (Schache et al., 2011). Due to this, the majority of HMI seen in professional football occur while high-speed running or sprinting (Wood et al., 2004). Brukner and Khan (2012) describes these as the common type I hamstring injury whilst type II, which are less common in football, occur during movements leading to extensive lengthening of the hamstring when in hip flexion such as high kicking and slide tackling. The high rate of re-injury in HMI could be due to inadequate rehabilitation programmes and/or poor return to

play (RTP) standards. (Askling et al. 2013). The primary objective of any rehabilitation protocol is to return the player back to the field of play in the shortest time possible whilst still ensuring that the risk of injury reoccurrence is minimal. This makes it a fine balance between getting right and being back to pre injury state after 20 days or getting it wrong and being in and out of rehab for a prolonged period of time. The standard protocol of increasing the eccentric strength of the hamstring muscles has been the proposed method of prevention and rehabilitation (Petersen et al., 2011). Brukner and Khan (2012) describe how little scientific evidence is available on which to base the management of hamstring injuries making it a problem in clinical practice as many approaches are experience based. Mendighucia and Brughelli, (2011) proposed a return to sport algorithm for acute hamstring strains. Although

football medic & scientist

Pictured: West Ham United’s Andy Carroll clutches at his hamstring before leaving the field injured in a game against Fulham in September 2012.

extremely usefull, especially in the acute setting which may not differ between sports, the data was gathered from different codes of sport, levels of competition and genders meaning that football specific demands on elite male players were not taken into account when developing the later phases of the algorithm. FC Barcelona have developed a muscle injury clinical guideline which they apply at their club from the academy level right through to the 1st team (FC Barcelona Medical Services, 2015) but this does not include a detailed exercise prescription for HMI rehabilitation. FIFA have also placed a large importance on football related injuries and have created the ‘11+’ warm-up and injury prevention manual which was developed by a group of international experts based on practical experience (FIFA, 2007). According to FIFA the the ‘11+’ can lead to a 30-50% reduction in injuries. Despite all research being put into injury prevention and rehabilitation there is still a current lack of evidence based rehabilitation protocols for HMI in football players. The purpose of this study was to critically analyse the current literature available pertaining to hamstring injury prevention and rehabilitation protocols in professional football to develop a standardized and reputable method of rehabilitation to implement in order to improve hamstring injury or re-injury rates in football players.

Table 1. Study stratification and level of evidence

Table 2. Summary of hamstring injury epidemiology in professional football players

METHOD: This narrative review of literature was based on articles found on the University of South Wales online database (http://studentlibrary. southwales.ac.uk/findit/). In order to identify

relevant literature, titles and abstracts were screened by the author using a strict inclusion criteria. Full text articles were read if eligibility could not be determined based on information found in the abstracts. The extracted information included methods, trial participant characteristics, type of intervention, type of outcomes and results. A total of 22 articles of a possible 567 were eligible according to the parameters set by the authors and were included in the final review (Table 1). RESULTS: This is only a summary of results. A full synthesis of results can be found in the online article posted on the FMA website. Synthesis of Results: Clinical assessment. US determinants of longer lay-off time included large cross-sectional area, injury outside of the musculotendinous junction, haematoma, structural injury and injury involving biceps femoris. Based on these results clinical and radiological assessment used together were seen as a useful tools in assessing HMI severity and provided accurate insight into lay off time and preventing future re-injury. Epidemiology. Nine studies included results on epidemiology of HMI in football players (Table 2). Details of these results can be found in the online article. Injury Prevention. Seven studies included results on hamstring injury prevention in football players (Table 3). Details of these results can be found in the online article.

Pictured: Middlesbroughâ&#x20AC;&#x2122;s Rudy Gestede feels his hamstring after pulling up with an injury during this yearâ&#x20AC;&#x2122;s FA Cup Quarter Final against Manchester City. Table 3. Summary of main findings from injury prevention studies.

Injury Rehabilitation. Seven studies looked at hamstring injury rehabilitation protocol (Table 4). Based on these recommendations involving injury rehabilitation: ~ CWTaT fPb P [PRZ Û TeXST]RT bd__âcX]V different rehabilitation protocols specific to football players. ~ <d[cX PacXRd[PcT Ud]RcX^] Û cWT WP\bcaX]V muscles was seen as one of the reasons these muscles are prone to injury in football player meaning that exercises involving simultaneous movement at the knee and hip needed to be used. ~ ?a^c^R^[ bcPVTb aP]VTS QTcfTT] " P]S & bcPVTb based on reaching certain recovery criteria before implementing a RTP protocol. ~ ;T]VcWT]X]V QPbTS TgTaRXbTb X\_aêTS aTRêTah speed as well as re-injury rates when compared to conventional rehabilitation exercises. ~ 7^\T QPbTS TgTaRXbTb Pb fT[[ Pb bd_TaeXbTS exercises were used in most of the protocols. Return to play. Seven studies analysed RTP factors in football players. Details of these results can be found in the online article. DISCUSSION The study investigated the common football specific practices which professional and semiprofessional medical teams utilize in order to improve hamstring injury rates and ensure a safe RTP for those who suffered a hamstring injury. With the use of the results from the studies above the authors would like to propose a protocol, specific to football players, which will help to analyse, prevent and rehabilitate

hamstring injuries. To view the injury prevention protocol suggested access the full online article.

confirms an HMI, the protocol will then be divided into the phases below:

Suggested protocol from time of injury to RTP Based on the above studies an individualized, 5 stage, criteria based protocol will be suggested in order to return the player from acute hamstring injuries (Figure 1). After the clinical assessment

1. Acute 1 & 2 2. Sub-Acute 3. Functional 4. Return to on field football-based exercises 5. Return to full competitive training

football medic & scientist

Pictured: Jose Mourinho consoles Paul Pogba as he is forced to leave the pitch with a hamstring injury during their Europa league game against FC Rostov. He is replaced by Marouane Fellaini. Table 4. Summary of rehabilitation recommendations from injury rehabilitation studies

Pictured: Burnleyâ&#x20AC;&#x2122;s Ashley Westwood (left) and Hull Cityâ&#x20AC;&#x2122;s Dieumerci Mbokani battle for the ball during a Premier League in February. Mbokani damaged his hamstring during the match. Table 5. Proposed history taking structure

The full details and rationale of the treatment model suggested can be found in the online article.

Table 6. Proposed post injury physical examination adapted from FC Barcelona Medical Services (2009)

CLINICAL ASSESSMENT: Immediately after injury is suspected through observation of the injury occurring, it is important to remove the player from the field of play. As hamstring strains are seen as obvious injuries the medical staff can quickly determine the need for the player to leave the field. This phase is crucial as a slight strain can quickly turn into a severe injury if the player is left to play on. During this post injury phase a clinical history of injury (Table 5) should be taken along with a simple physical exam (Table 6). The treatment modality for this stage should follow the standard RICE protocol. At this time establishing severity through further investigations may not be sensitive enough and medical teams are therefore encouraged to wait at least 12-24 hours before US or MRI scans. Based on these findings the hamstring injuries can then be classified according to severity on order to derive the prognosis. The table below (Table 7) shows the classification of these injuries according to imaging criteria and is adapted from Medical Services, Futbol Club Barcelona (2009). Using the results of the clinical and radiological examination the medical team can then decide on the correct course of action to manage the acute hamstring injury. ACUTE PHASE: The acute phase of hamstring injuries will not differ from the standardized rehabilitation algorithm by Mendiguchia and Brughelli, (2011) or the treatment protocol found in Medical Services, Futbol Club Barcelona (2009) and therefore will be adapted from their recommendations. It is suggested that the acute stage of muscle injuries is divided into 2 phases (Table 8 & 9). The criteria needed to be achieved at this

football medic & scientist acute stage are:

Figure 1. Proposed Management model for the treatment of acute hamstring injuries.

~ ?PX] UaTT fP[ZX]V ~ =^ _PX] â SXbR^\Uâc SdaX]V TgTaRXbTb ~ 5d[[ PRcXeT _PX] UaTT Z]TT A>< ~ 8b^\TcaXR Z]TT TgX^] bcaT]VcW X] _a^]T with knee flexion at 45Â° and hip at 0Â°, > 50% of previous data or compared to uninjured leg with the use of a dynamometer ~ :]TT TgX^] bcaT]VcW - $ Û d]X]YdaTS [TV Pc 45Â° and 90Â° knee flexion with the use of manual strength tests (if dynamometer is not available) Once all these criteria have been reached the player may be advanced to the next phase of rehabilitation. If not all criteria are met the player should be advised to continue with the same phase for an additional 2-3 days before being re-tested.

Table 7. Classification of muscular injuries according to imaging criteria

SUB-ACUTE PHASE: The sub-acute phase of hamstring injuries (Table 10) will be implemented once the player has reached the advancement criteria set out during the acute phase. The progression between easy, moderate and advanced exercises needs to be based on clinical experience as well as pain/ discomfort scales and any other factors which may lead to detrimental adaptations of the hamstring muscle. The criteria needed to be achieved at this subacute stage are:

Table 8. Acute phase 1 of hamstring rehabilitation

~ =^ _PX] â SXbR^\Uâc SdaX]V P]h TgTaRXbTb ~ 0QX[Xch c^ Y^V Q^cW UâfPaSb P]S QPRZfPaSb Pc P moderate speed ~ 8b^\TcaXR Z]TT TgX^] bcaT]VcW Pc !$Â&#x2014; Z]TT flexion and 45Â° hip flexion, at less than 10% asymmetry from previous data or uninjured leg with the use of a dynamometer ~ 5d[[ $ $ bcaT]VcW fXcW^dc _PX] SdaX]V _a^]T knee flexion at 90Â° with manual strength tests if dynamometer is not available ~ ?[PhTa bW^d[S QT PQ[T c^ _PacXRX_PcT X] functional movements such as deep squats, single leg squats and lunges without any pain or discomfort Once all these criteria have been reached the player may be advanced to the next phase of rehabilitation. If not all criteria are met the player should be advised to continue with the same phase for an additional 2- 3 days before being re tested.

Table 9. Acute phase 2 of hamstring rehabilitation

FUNCTIONAL PHASE: The functional phase of hamstring injury rehabilitation can only be implemented once the player has reached all of the criteria set out during the sub-acute phase. A gradual progression from the sub-acute phase is needed as the functional phase is implemented (Table 11.) A decrease in re-injury rates has been shown as a result of more time spent on the field during a rehabilitation protocol and it is suggested that players undergoing the functional phase of rehabilitation begin to spend 2/3 days a week on field taking part in the more sports specific exercises activities allowed during this phase. At this functional stage the player should be taking part in these exercises 5 to 7 times a

Table 10. Sub-Acute Phase recommendations

week as well as beginning to incorporate the preventative routines set out by the medical team for other joints allowing the player to take part in these ‘controlled’ training sessions with the rest of team provided that these exercises do not compromise the injured hamstring muscle. The criteria needed to be achieved in this functional phase are: ~ =^ _PX] â SXbR^\Uâc SdaX]V TgTaRXbTb ~ 8b^\TcaXR Z]TT TgX^] bcaT]VcW fXcW Z]TT at 0° and maximum hip flexion same to that achieved on the contralateral leg. (<10% asymmetry) ~ =â\P[ Xb^ZX]TcXR aPcX^b P]S ]^ \âT cWP] 10% asymmetry in absolute values ~ =^ Pbh\\Tcah X] PRcXeT bcaPXVWc [TV aPXbT and active knee extension test Once all these criteria have been reached the player may advance to the next phase of rehabilitation. At this point the medical team will give the ‘medical all-clear’ as the player returns to field based exercises. If not all criteria are met the player should be advised to continue with the same phase for an additional 2- 3 days before being re tested.

Table 11. Functional Phase recommendations

RETURN TO ON FIELD FOOTBALL-BASED EXERCISES (RTP) During this phase the football player is allowed to return to the field of play, in a controlled training setting, and is able to take part in football related activities. You can view the RTP 1 and RTP 2 protocols in the full online article. CONCLUSION Hamstring muscle injury is a pertinent issue in professional football players. Correct prevention and management strategies need to be followed by medical teams in order to decrease the chance of hamstring injury and re-injury. Screening for risk factors and implementing the suggested preventative programme to the players in need is a way to decrease the changes of HMI. If a footballer sustains a HMI the correct rehabilitative management needs to be implemented. In order to do this a multidisciplinary team approach lead by the team doctor is suggested along with a 5 stage, criteria based, individualized rehabilitation protocol for the player in need. Up on return to sport a gradual introduction to full training and matches is suggested where the risks of early return need to be weighed up with the risks of hamstring reinjury. In this critical review, a gap between evidence base and actual clinical practice in professional football teams was noted and it is important that the medical team always delivers interventions based on evidence that is available. Although the individual methods suggested in the above recommendations are evidence based, the protocols as a whole are novel ones and therefore further studies are needed to verify the effectiveness of the proposed preventative and rehabilitative protocols in a field setting.

football medic & scientist

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Pictured: Jim (second left) watches on from the Manchester United bench alongside substitute Norman Whiteside, assistant manager Mick Brown and manager Ron Atkinson, during a 1984 match against West Bromwich Albion.

WHERE ARE THEY NOW? FEATURE/ JIM MCGREGOR

qualified as a Chartered Physiotherapist in 1963 and started in the NHS working with physically and mentally handicapped children. My aim was always to work in professional football, and I was lucky to get an early foot on the ladder by working part-time with the Scottish League club Clyde, based in Glasgow. In 1966, I noticed an advert in my professional journal for a qualified physiotherapist with an English Third Division club, Oldham Athletic. I applied for the job, and after an interview with the club doctor, the manager, who was the great ex-Burnley and Northern Ireland player Jimmy McIroy, and the chairman, the formidable Ken Bates, I was offered the full-time post. After a very happy and successful nine years with the Latics, I moved to Everton, which was just as happy but not quite as successful. After six years with the Toffees, Ron Atkinson lured me to Manchester United, where I was to spend the next thirteen years of my football career. Although I never had a mentor as such, many people in the game influenced me on the psychology of treating players with different personalities, especially those

facing a long time out of the game through injury. No player enjoys being injured, so I made sure that the atmosphere in my treatment room, although always professional, was also a happy one. I had great admiration and affection for many people in the game throughout my career, including staff and players, and of course many of the eight managers I had

the pleasure to work with in my twenty eight years working in the four leagues of English Football. Jimmy Frizzell at Oldham was my boss and best pal. Gordon Lee at Everton was the most sincere man imaginable, and Ron Atkinson was charisma personified. I loved the scouse lads at Everton, and had great relationships with several of the United players. Norman Whiteside never forgets my birthday, and Andre Kanchelskis telephones on Christmas Day. The best part for me working in football was the camaraderie, so when I left in 1994, I really missed the dressing room banter, the amusing stories in the medical room and the emotional highs and lows of match days. I am lucky to still meet up once a week with a group of ex-Everton players and staff, which refreshes my memory of happy days gone bye. Although I like to think that I was a competent physiotherapist and totally dedicated to sports injuries, I was first and foremost a football man with a reasonable insight into the game, which I feel helps greatly in understanding football injuries. I loved the game, and still do, hoping that some day soon, Everton might just win the Premiership !! Obviously, I have a plethora of memorable moments in my career. I was fortunate to experience seventeen visits to Wembley. Emerging from that tunnel never fails to set the nerves tingling, even although you are only a bit player. The atmosphere in Rotterdam for the 1991 Cup Winners Cup Final against Barcelona had me shaking with excitement, but the most enjoyable and therefore the most memorable period of my football life was working as Physiotherapist to the Northern Ireland football team in the 1982 World Cup in Spain. Little Northern Ireland, with ten men, beat the mighty Spanish in Madrid to reach the Quarter Finals. I ran out of headache tablets the next morning !!!! My first experience of being at the sharp end of serious injuries on the pitch will remain with me for the rest of my life, as it was, to this day, the worst injury I was ever to be involved with. It was my second

Pictured: Manchester United physio Jim McGregor has a laugh with Unitedâ&#x20AC;&#x2122;s Paul Parker and Bryan Robson

Pictured: Images of Jim from across his career.

match in English football, and Oldham were playing at Middlesbrough. I hadn`t even taken my seat on the bench before I was called on to our Northern Ireland striker, Billy Johnson. I was confronted with the worst-imaginable compound- fracture dislocation of the ankle. Billy`s foot was rotated 180 degrees, his tibia and fibula were split nearly six inches apart, and an artery was spurting blood on to my hands and arms as I tried to comprehend what I was experiencing. This was my harsh introduction to the world of professional sports injuries. Billy never fully recovered from the injury, but he and his wife became very good friends of my wife and I, and remain so to this day. Naturally, much has changed in football since I left in 1994. The MRI scan was just in it`s infancy as a diagnostic tool, and like every great innovation, there are always a few negatives. My biggest asset as a sports physiotherapist was my ability to accurately diagnose an injury, usually on the field of play, and also be able to provide a pretty precise time-scale for recovery in most soft tissue and joint injuries. I had learned from a wonderful physiotherapist in Glasgow how to palpate, usually with my eyes shut, ( Eric Cantona mentions this in his book ), to recognise by touch, irregular contours, abnormal densities, and different localised areas of excessive muscular

tension. I made most of the decisions myself, as club doctors in those days were usually at the matches to enjoy the sandwiches at half-time and the whisky at full-time. I realise that most doctors in sport now have undertaken some form of post-graduate sports medicine training, but it does not deter me from screaming at the TV on match days when two pairs of hands are fumbling around one ankle or knee, and neither the physiotherapist or doctor seem very confident about what they are actually doing!! Doctors, in my opinion, should only be on the pitch if there is a head injury, or if the physiotherapist beckons him on for help. I would have found the presence of a doctor, even one well-versed in sports injuries, a massive hindrance. The scan is a superb diagnostic implement, but it is usually at least twenty four hours or longer before an accurate assessment is made, and because it is readily available, the diagnostic expertise of the physiotherapist is not so vital, and so not so important to learn. Managers frequently state that they do not know the exact nature of the injury until they get the results of the scan, and of course they have very little idea how long the player will be out of action because the scan can diagnose but not prognosticate! I am astonished at the number of back-room staff on the seats behind the

manager and his assistant. I am informed that most kit managers have one, two or three assistants now. When I was at Everton, I did all the treatments singlehanded, the rehabilitation, the massaging, the pre-match warm-ups, the chiropody, and helped the first team coach, I repeat, the first team coach lay out the kit and boots in the dressing on match days, and pack the skips for away games. I never complained about my different duties because I enjoyed doing it! I have to add that some of the warm-up routines seem to be a show for the warm-up man and, in my opinion, too prolonged. Players are actually getting injured in these warm-ups, and I read recently that one got injured in the warm-down!!! I shouldn`t end on a cynical note, so I will sign off by saying that I was a very lucky man indeed to have such a happy and rewarding career in what is still the greatest game in the world. At the age of seventy five, I still can`t get enough football. When it`s too cold for gardening, I nip along the road to watch Burscough FC in the Evostick League North. I have a little house in the Languedoc in France which takes up three months of my year, and I live in the lovely village of Parbold with great country walks and pubs. Yes, I`ve been ultra-lucky, and I`d love to do most of it all again!

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