Perspectives in football medicine

Impact of the COVID-19 Pandemic on Injury Incidence in Japanese Male Professional Soccer Players

Background

The outbreak of the 2019 novel coronavirus disease (COVID-19) led to an enforced quarantine period and limited training and match activities for athletes.

Purpose

To report the influence of the COVID-19 pandemic on the occurrence of injury in Japanese male professional soccer players.

Study Design

Descriptive epidemiology study.

Methods

In total, 21 clubs in the 2019 season and 28 clubs in the 2020 season from the Japan Professional Football League were prospectively followed, and 16 clubs in 2019 and 24 clubs in 2020 were analyzed in this study. Individual training, match exposure, and time-loss injuries were recorded using an electronic data capture system. The influence of COVID-19-related suspension during the 2020 season was retrospectively investigated via comparisons with the 2019 season.

Results

Total activity time included 114,001 hours in training and 16,339 hours in matches in 2019 and 170,798 hours in training and 25,411 hours in matches in 2020. The mean training interruption period caused by COVID-19 in 2020 was 39.9 days (range, 3-65 days), and the mean game-interruption period was 70.1 days (range, 58-79 days). The total number of injuries was 1495 in 2019 and 1701 in 2020. The overall injury incidence per 1000 hours of exposure was 5.7 in 2019 and 5.8 in 2020. The overall injury burden per 1000 hours of exposure was 155.5 days in 2019 and 130.2 days in 2020. The muscle injury incidence was highest in May 2020, immediately after the suspension period.

Conclusion

The overall injury incidence did not differ between 2019 and 2020. However, muscle injury incidence notably increased in the 2 months after the COVID-19 pandemic suspension period.

Hamstring injury rates have increased during recent seasons and now constitute 24% of all injuries in men's professional football: the UEFA Elite Club Injury Study from 2001/02 to 2021/22

OBJECTIVES

To: (1) describe hamstring injury incidence and burden in male professional football players over 21 seasons (2001/02 to 2021/22); (2) analyse the time-trends of hamstring muscle injuries over the most recent eight seasons (2014/15 to 2021/22); and (3) describe hamstring injury location, mechanism and recurrence rate.

METHODS

3909 players from 54 teams (in 20 European countries) from 2001/02 to 2021/22 (21 consecutive seasons) were included. Team medical staff recorded individual player exposure and time-loss injuries. Time-trend analyses were performed with Poisson regression using generalised linear models.

RESULTS

2636 hamstring injuries represented 19% of all reported injuries, with the proportion of all injuries increasing from 12% during the first season to 24% in the most recent season. During that same period, the percentage of all injury absence days caused by hamstring injuries increased from 10% to 20%. Between 2014/15 and 2021/22, training hamstring injury incidence increased (6.7% annually, 95% CI 1.7% to 12.5%) as did burden (9.0% annually, 95% CI 1.2% to 18.3%). During those years, the match hamstring injury incidence also increased (3.9% annually, 95% CI 0.1% to 7.9%) and with the same trend (not statistically significant) for match hamstring injury burden (6.2% annually, 95% CI -0.5% to 15.0%).

CONCLUSIONS

Hamstring injury proportions-in number of injuries and total absence days-doubled during the 21-year period of study. During the last eight seasons, hamstring injury rates have increased both in training and match play.

Psychosocial aspects of sports medicine in pediatric athletes: Current concepts in the 21st century

Behavioral aspects of organized sports activity for pediatric athletes are considered in a world consumed with winning at all costs. In the first part of this treatise, we deal with a number of themes faced by our children in their sports play. These concepts include the lure of sports, sports attrition, the mental health of pediatric athletes (i.e., effects of stress, anxiety, depression, suicide in athletes, ADHD and stimulants, coping with injuries, drug use, and eating disorders), violence in sports (i.e., concepts of the abused athlete including sexual abuse), dealing with supervisors (i.e., coaches, parents), peers, the talented athlete, early sports specialization and sports clubs. In the second part of this discussion, we cover ergolytic agents consumed by young athletes in attempts to win at all costs. Sports doping agents covered include anabolic steroids (anabolic-androgenic steroids or AAS), androstenedione, dehydroepiandrostenedione (DHEA), human growth hormone (hGH; also its human recombinant homologue: rhGH), clenbuterol, creatine, gamma hydroxybutyrate (GHB), amphetamines, caffeine and ephedrine. Also considered are blood doping that includes erythropoietin (EPO) and concepts of gene doping. In the last section of this discussion, we look at disabled pediatric athletes that include such concepts as athletes with spinal cord injuries (SCIs), myelomeningocele, cerebral palsy, wheelchair athletes, and amputee athletes; also covered are pediatric athletes with visual impairment, deafness, and those with intellectual disability including Down syndrome. In addition, concepts of autonomic dysreflexia, boosting and atlantoaxial instability are emphasized. We conclude that clinicians and society should protect our precious pediatric athletes who face many challenges in their involvement with organized sports in a world obsessed with winning. There is much we can do to help our young athletes find benefit from sports play while avoiding or blunting negative consequences of organized sport activities.

Traumatic Leg Fractures in UEFA Football Athletes: A Matched-Cohort Analysis of Return to Play, Reinjury, Player Retention, and Performance Outcomes

Background:

The average professional soccer team experiences 1 to 2 traumatic leg fractures per season, with unknown effects on player performance.

Purpose:

To (1) determine the rate and time to return to play (RTP) following leg fracture, (2) investigate the rate of reinjury following RTP, and (3) investigate long-term effects that lower extremity (LE) fracture may have on elite soccer player performance.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Using publicly available records, we identified athletes sustaining a traumatic leg fracture across the 5 major European soccer leagues (English Premier League, Bundesliga, La Liga, Ligue 1, and Serie A) between 2000 and 2016. Athletes with leg fracture (femur, tibia, and/or fibula) were matched 1:2 to controls by demographic characteristics and performance metrics 1 season before the index timepoint. Investigations included the RTP rate, reinjury rate, player characteristics associated with RTP within 2 seasons, long-term player retention, performance metrics during the 4 following seasons, and subgroup analysis by player position.

Results:

A total of 112 players with LE fracture and 224 controls were identified. Players with LE fractures were absent for a mean of 157 days (range, 24-601 days) and 21 games (range, 2-68 games). The rate of RTP within 1 season was 80%, with 4% experiencing subsequent refracture. Injured players remained active in the league at a higher rate than their uninjured counterparts. As compared with controls, injured athletes played 309 fewer total minutes (P < .05), scored 0.09 more assists per game (P < .01) 1 season after injury, and scored 0.12 more points per game 4 seasons after injury (P < .01). Defenders were most affected by an LE fracture, playing 5.24 fewer games (P < .05), 603 fewer total minutes (P < .01), and recording 0.19 more assists per 90 minutes of play as compared with controls 1 season after injury (P < .001). Attackers and midfielders demonstrated no significant difference in metrics after RTP when compared with controls.

Conclusion:

Most players sustaining an LE fracture returned to elite soccer at the same level after a significant loss of playing time, with a 4% rate of refracture. Player retention was higher for those sustaining an LE fracture versus uninjured controls. Overall, injured players did not experience a decline in performance after recovery from an LE fracture.

Indirect Structural Muscle Injuries of Lower Limb: Rehabilitation and Therapeutic Exercise

Muscle injuries are the most common trauma in team and individual sports. The muscles most frequently affected are those of the lower limb, and in particular hamstrings, adductors, rectus femoris and calf muscles. Although several scientific studies have tried to propose different rehabilitation protocols, still too often the real rehabilitation process is not based on scientific knowledge, especially in non-elite athletes. Moreover, the growing use of physical and instrumental therapies has made it increasingly difficult to understand what can be truly effective. Therefore, the aim of the present paper is to review proposed therapeutic algorithms for muscle injuries, proposing a concise and practical summary. Following a three-phase rehabilitation protocol, this review aims to describe the conservative treatment of indirect structural muscle injuries, which are the more routinely found and more challenging type. For each phase, until return to training and return to sport are completed, the functional goal, the most appropriate practitioner, and the best possible treatment according to current evidence are expressed. Finally, the last section is focused on the specific exercise rehabilitation for the four main muscle groups with a structured explanatory timetable.

Decision-making to stop or continue playing after football injuries - a systematic video analysis of 711 injury situations in amateur football

Scientific injury registration via video analysis is lacking in amateur football. The purpose of this study was to analyse match injury situations with a focus on the decisions made by players and referees after sustaining a football trauma. In a retrospective cohort study, traumatic injuries sustained in any of the 305 matches of the highest amateur level (4th league) in Germany in the 2015-16 season were assessed by means of video analysis and a standardised video protocol. In total, 711 traumatic incidents at 919 different body regions had been recorded. The three most frequently injured body regions were the ankles (34.1%), the head (17.5%) and the knees (17.0%). 90% (n = 156) of head injuries were direct contact injuries, this percentage was significantly higher than that of contact injuries on ankle (68.4%; p < 0.001) or knee (52.6%; p = 0.001). Referees decided on foul play significantly more often in case of knee injuries (57.1%; p = 0.002) or ankle injuries (64.5%; p < 0.001) than in head injuries (39.8%). Only 26.1% of players with a head injury opted for substitution, which was lower than after ankle (27.8%; p = 0.78) and knee injuries (34.0%; p = 0.13). In conclusion, amateur football is associated with a considerable number of injury situations that are followed by match interruptions and the substitution of players. Players and referees decided to continue playing more often after a head injury than after an injury to other body regions. An advanced education programme on the risks and management of head injuries in football is required to prevent long-term health consequences.

Is It High Time to Increase Elite Soccer Substitutions Permanently?

Rules determine how team sport matches occur. Match-induced fatigue is specific to each sport, and may be associated with injury incidence. For example, the injury rate in soccer is distinctly higher during matches than in training sessions. Understanding the differences between team sports rules might be useful for enhancing rules (e.g., safer sport). Therefore, this study aimed to evaluate the impact of the rule-induced physical demands between soccer, futsal, basketball, and handball, focusing on substitution rules. Data from the elite team sports' rules (e.g., absolute and relative court dimensions; the number of players, substitutions allowed, total game time, time-outs) were collected, including the changes due to the coronavirus disease (COVID-19) pandemic in soccer substitutions, and comparisons were performed. The data showed that soccer has higher rule-induced physical demands: e.g., substantially lower substitution rate, higher dimensions in absolute (eight to fifteen times), and relative (four to eight times) values. Simulations also showed that soccer has extremely large differences, even considering COVID-19 substitution changes (from three to up to five). We conclude that elite soccer has remarkably higher overall rule-induced physical demands than elite futsal, basketball and handball, and increasing soccer substitutions permanently (e.g., unlimited) might mitigate overall soccer demands.

[How dangerous is American football in a German amateur league? An injury analysis according to playing position over a period of four seasons]

BACKGROUND

American football is known for its high risk of injury, especially in the professional field. Although the number of players in the German football league (GFL) has risen in recent years, data concerning the injury rates of German amateur players in American football are scarce.

OBJECTIVE

Analysis of the injury rates in league games and training sessions in amateur football according to playing positions and body region.

MATERIAL AND METHODS

Injuries of 123 American football players in a club playing in the second GFL (first and second team) were prospectively recorded over a period of 4 seasons (2014-2018). A complete history of injuries was obtained from 72 players. The injuries were classified using the Orchard sports injury classification system 10.1 (OSICS 10.1). The injury rates were calculated per 1000 athlete exposures (AE) for training as well as for league games with respect to the playing position and for each body region.

RESULTS

Overall 142 injuries were recorded. On average there were 35.5 injuries per season and 1.9 injuries per player. Of the injuries 54.7% occurred during training and 46.1% during games. The risk of injury was significantly increased during league games (15.6 ± 16.3) compared to training (3.1 ± 2.7, p < 0.0001). While wide receivers and cornerbacks had the highest overall injury rates, running backs had the highest injury risk during games (p = 0.046). Injuries to knees (27.3%) and shoulders (20.1%) were the most frequent. The shoulder was the body region injured most frequently during games (p = 0.002). Regarding the injury pattern, distorsions (30.9%) and contusions (22.5%) occurred more often compared to fractures (12.6%) and dislocations (16.1%). Concussion only contributed to 2.9% of the injuries.

CONCLUSION

American football is a contact sport with high injury rates even in the German amateur field, especially during league games. Regarding body regions, shoulders and knees were predominantly affected while regarding the playing position, wide receivers and cornerbacks were particularly jeopardized. Therefore, a continuous close medical supervision during games and an intensive position-specific training seem to be necessary even in the amateur field in order to reduce the injury rate.

Italian consensus statement (2020) on return to play after lower limb muscle injury in football (soccer)

Return to play (RTP) decisions in football are currently based on expert opinion. No consensus guideline has been published to demonstrate an evidence-based decision-making process in football (soccer). Our aim was to provide a framework for evidence-based decision-making in RTP following lower limb muscle injuries sustained in football. A 1-day consensus meeting was held in Milan, on 31 August 2018, involving 66 national and international experts from various academic backgrounds. A narrative review of the current evidence for RTP decision-making in football was provided to delegates. Assembled experts came to a consensus on the best practice for managing RTP following lower limb muscle injuries via the Delphi process. Consensus was reached on (1) the definitions of 'return to training' and 'return to play' in football. We agreed on 'return to training' and RTP in football, the appropriate use of clinical and imaging assessments, and laboratory and field tests for return to training following lower limb muscle injury, and identified objective criteria for RTP based on global positioning system technology. Level of evidence IV, grade of recommendation D.