MEDICINE - UEFA · 2015-04-10 · MEDICINE MATTERS/3 EDITORIAL It was also a good idea to mix...

APRIL 2010 – No.18

IN THIS ISSUE

PUBLISHED BY UEFA’S FOOTBALL

DEVELOPMENTDIVISION

SWEDISHSMÖRGÅSBORD

SCIENCE – MAKING A DIFFERENCE IN MODERN FOOTBALL?

MEDICAL STAFF AND REFEREES

THE FEMININEFACTOR

MEDICINEMatters

MedicineMatters18E8.0:Anglais 12.03.10 14:00 Page1

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COVERPhilipp Lahm (Bayern Munich) up against Juan Vargas (Fiorentina) in the UEFA Champions League round of 16. The physical intensityof top-flight football necessitates first-rate medical care.Photo: Pollex/Bongarts/Getty Images

ship among colleagues who face the same challenges. Creditfor this must go to the UEFA staff and the Swedish nationalassociation who created, aroundthe symposium, an ambiencewhich was perfect for listening,discussing and learning. I wenthome with an exceptionally good feeling and with a clearview of the issues which currentlyconcern team doctors and, forthat matter, the UEFA MedicalCommittee which, with five newsignings in the line-up, made its first appearance of the2009–11 campaign in Stockholm.It is always good to combine the input and fresh ideas fromnew colleagues with the accu-mulated wisdom of those who have been members of thecommittee for many years.

Firstly, I was enthusiastic about the quality of the presentations and the fact that they addressedgenuine problems in modern-dayfootball medicine (as opposed to sports medicine), such as the prevention of sudden deaths, thestudy of injury patterns, the epi-demiology of lesions and, I wouldsay, a remarkable session led by the former top referee MarkusMerk who, despite the difficultiesendemic to the job, made it clearthat he felt the referee’s prime duty is – like ours – to protect thehealth and safety of the players.There was not a single presentationthat failed to teach me something.

Secondly – and equally importantly– I was impressed by the fantasticcollegiate atmosphere in Stockholm.There was an ambience of friend-

A FANTASTICE D I T O R I A L G R O U P

Andy RoxburghGraham Turner

P R O D U C T I O NAndré VieliDominique MaurerAtema Communication SA,Gland, SwitzerlandPrinted by Artgraphic Cavin SA,Grandson, Switzerland

A D M I N I S T R AT I O NDavid GoughFrank LudolphEvelyn TernesUEFA Language Services

I M P R E S S U MThis issue of Medicine Matters is being compiled

in the aftermath of the fifth UEFA Medical Symposium,

staged in Stockholm in February. After so many years

in football medicine, it is unusual for me to be so

enthusiastic about an event. But this one was very,

very satisfying for two reasons.


MEDICINE MATTERS/3

EDITORIAL

It was also a good idea to mix doctors from 52 of UEFA’s memberassociations with colleagues fromthe top clubs who are participatingin our ongoing injury study andwho, day in, day out, are workingat the stadium or the training centre. It was an excellent blendand one which reinforced my viewthat, at elite level, the ‘team doc-tor’ doesn’t really exist any more.The medical care of a squad ofplayers has become so complex thata single person cannot be a ‘masterof all trades’. These days, we aretalking about a ‘medical team’which needs to communicate effi-ciently with the coaching and man-agement staff and which, to be efficient in terms of enhancing per-formance, must be fully integratedinto the daily life of the group.

Of the many issues raised duringthe symposium, several will bementioned in the following pages.So I will not try to touch on all ofthem now. However, some of themare fundamental. I was informed,for example, that there are still five

BY DR MICHEL D’HOOGHEChairman, UEFA Medical Committee

European national associations thatdo not have a medical committee. I believe that it is a prime obligationto create one and to give it admin-istrative, financial and political sup-port. The creation of an anti-dopingunit is also an absolute must.

In Sweden, we also looked at crit-ical subjects which are of special interest to me – and, I believe, tomy colleagues in football medicine.For instance, we could do worsethan to look very carefully at ourown roles and establish criteriawhich will help us to define exactlywhat qualifications are required by a doctor who sits on the benchduring matches and who may, inaddition to more routine occur-rences, have to deal with challeng-ing emergencies. Two of my col-leagues on the Medical Committee,Mehmet Binnet and MogensKreutzfeldt, are to be credited forsome excellent groundwork in this area. The evidence provided by their pilot study will, I am sure,be invaluable when it comes to deciding whether establishing stan-

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dardised football-specific quali-fications is a viable project or not.

I underline the term ‘football-specific’. Stockholm was not ‘justanother medical congress’. It was,from start to finish, a football-specific event. Medical matterswere always related directly to thegame of football. It led to an in-vigorating variety. In a single day,topics ranged from an in-depthlook at doping controls and theiraccuracy to various perspectives on how medicine can best servethe player and, bearing in mindthat, in the women’s game, Ger-many cannot seem to stop winningtitles, it was appropriate that Dr Ulrich Schneider should addressthe specificities of women’s foot-ball. UEFA’s technical director, AndyRoxburgh, also contributed twomotivational presentations on the‘team behind the team’ and the future of football. Amidst all that,the discussion sessions emphasisedthat, even if we have come a longway in football medicine, there is still a lot of work to be done.


Anti-doping programmeThis may not be the tastiest of dishes butit has become, over the years, the teamdoctors’ staple diet. Dr Jacques Liénard, a long-standing member of UEFA’s Med-ical Committee, reported that, over thelast decade, the number of tests con-ducted under UEFA auspices has risenfrom 208 to 1,748 per season and that 15 years of in-competition controls haveuncovered 29 positive cases in 10,419tests – a figure of 0.28%. As Dr MichelD’Hooghe commented, “the costs of thetesting programme are considerable, but the results demonstrate that there isno doping culture in football”.

One codicil to the figures is that 9 ofthe 29 tested positive for cannabinoidsand 2 for cocaine. Only 11 were attrib-utable to anabolic agents, glucocor-ticosteroids, Beta-2 agonists or, in onecase, diuretics susceptible to be used as masking agents.

In Stockholm, the focus was thereforeon procedural details rather than ‘dop-ing culture’. The new requirements interms of the specific gravity of sampleshave revealed that the digital refrac-tometer is the best provider of reliablereadings. The increase in the volume ofsamples from 75 to 90ml resulted in

only 45 of 1,728 tests last season fallingshort of the mark (2.6%), with 78% of those occurring during out-of-com-petition testing.

No fewer than 81% of therapeutic useexemptions were due to asthmatic con-ditions, with Nordic countries providingthe lion’s share of TUE (therapeutic useexemption) applications.

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SWEDISHSMÖRGÅSBORDFor the average visitor to Sweden, the smörgåsbordis the typical buffet-style meal of various hot and cold dishes. It might not be stretching the imagination too far to claim that the participants at the recent medical symposium in Stockholm were offered football medicine’s equivalent. The menu for the three-day event was certainly varied – so much so that maybe the best thing to do is pick up a fork or a handful of cocktail sticks, walk around the smörgåsbord table and take a few tasters.

The equipment for a doping control

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Dr Jacques Liénard, member of the Anti-Doping Panel, at the symposium in Stockholm

Among the match-related issues wasthe draw conducted in the doping con-trol room 15 minutes before the end of the game – the general opinion being that this should be attended by ateam administrator, in preference toleaving the bench medically unguardedwhile the team doctor is inside.

Out-of-competition testing also pro-duces some logistical hiccups, largely related to the implementation of the‘whereabouts’ ruling. Let’s imagine the two doping control officers ringing the bell at the gates of a trainingground, only to be told that, on the


previous evening, the coach had decided– bearing in mind the team’s workloadand the climatic conditions – to give theplayers a day off. On the one hand,there are understandable demands forthe sanctions in such a case to be severe(in order to pre-empt abuse) while, onthe other hand, how easily is the coachgoing to be persuaded not to change hisplans on the remote chance of a dopingcontrol? In the current environment, it istherefore essential for clubs to fine-tunetheir communication procedures so thatinformation can be passed as rapidly as possible to the doping control unit.

Referees and injured playersMarkus Merk, the former elite refereewho handled the 2003 UEFA ChampionsLeague and EURO 2004 finals, was inStockholm to discuss injuries. “The players’ most important capital is theirhealth,” he said, “and our priority is toprotect and safeguard it.”

He also made the interesting point that,in a way, the referee is the first to assessan injury. “Our duty involves assessingthe injury risk attached to certain typesof situation. The 1990 World Cup wasthe first event to highlight this by look-ing at the dangers of the tackle from behind. Awareness has risen steadilysince then and there is increasing pres-sure on today’s referee in terms of as-sessing fouls and injuries. We sometimesdon’t get as much help as we would like.For example, how many winning teamsget ‘injuries’ near the end of the match?We want to allow play to flow, so wehave to make instant assessments beforewe react to a fallen player.”

The theme was picked up in a couple of the discussion groups. Apart from debate on how far the punishmentshould be influenced by the referee’s assessment of the severity of the injury,there was a look at situations where

the referee frustrates the team doctor by putting the brakes on his desire toget onto the pitch. And there was debate about the best procedures fordealing with the treatment of blood injuries – another area of potential antagonism between referee and doc-tor. Markus had the last word: “If the doctor is called onto the pitch, it is to treat the player – not to argue withthe referee about his decisions!”

The team behind the teamThe importance of the team doctor andhis relationship with the coach was oneof the core themes in Stockholm. By extension, it generated exchanges ofviews on the increasing tendency forcoaches to take members of the medicalstaff with them when they move to adifferent team. It is an understandablemove for coaches and doctors who have

developed a relationship of mutualtrust and respect. Looking at the otherside of the coin, however, it can be badnews for a doctor who has been per-forming efficient work at a club, only to be ousted by the newcomer.

It raises questions about career path-ways for the football doctor. Is it bestto be attached to a club? Or is it moreviable to become attached to a coach?Similarly, is the fitness coach to be considered a member of the coachingstaff? Or part of the medical team?

Stress fracturesThese are such a rare occurrence thatclubs asked UEFA to collate data whichcould be used to draw comparisons andoffer pointers towards best practice.The incidence in elite male football is 0.04 stress fractures per 1,000 hours

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Former referee Markus Merkwas on hand to present the referees’ point of view.

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It is up to the referee to judge how serious an injury is and to act accordingly.


of exposure and, in a squad of 25, themedical team can be expected to en-counter one every three seasons. Withinthe context of rarity, it’s interesting tonote that the risk of this type of injury isdouble during pre-season.

Stress fractures generally affect youn-ger players, with 80% of injuries in-volving the under-26 age group. Fifthmetatarsal fractures became topicalwhen they affected elite players, andthe team doctor can expect to deal with44 muscle injuries for every metatarsalinjury. A study based on 30 MT5 frac-tures revealed that, of the 18 operatedplayers, the average absence was 87 days against 63 days for non-oper-ated players. However, there were fourcases of non-union in each group –which meant that the incidence is one in three if the non-surgical option is preferred.

Medical action plansCardiac arrests and sudden death are,unfortunately, topical issues. But, inStockholm, the subject was put into abroader context. Prof. Mats Börjesson,cardiologist and member of the Swedishassociation’s medical committee, startedby reviewing the importance of reactiontimes to cases of cardiac arrest and then used a wider lens to focus on thestands as well as the pitch. He com-mented on a survey of 190 Europeanclubs which, even though the study wascompleted in a single season, revealedwidely differing degrees of arena safety.

He also invoked a series of observationsmade by one of the members of his au-dience: Luís Serratosa, head of medicalservices at Real Madrid CF. Betweenthem, they pinpointed potential difficul-ties in dealing with medical emergenciesin the stadium: the need to navigatelarge crowds, often with no clear land-marks; the frequent existence of barriers

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to access or even accreditation prob-lems; the extremely limited possibility of exploiting motorised transport; thechance that the casualties might be multiple; potentially dangerous environ-mental conditions; and, even if all that is surmounted, there might be a patientwho is reluctant to leave the stand and miss the action. Hence the need todraw up a coherent medical action plan and brief the appropriately trainedpersonnel on how to implement it.

The flying doctorHow can you guarantee the team doctora comfortable away trip? You eliminatethe niggling worries that he or she carries on to the plane. Insurance, forexample. How many policies include in the small print a clause about cover-ing only the work performed on hometerritory? Is enough attention paid to this aspect when age-limit teams areon the road?

These were among the questions toemerge from the discussion groups,where a chorus of voices called for

greater interchanges of informationaimed at allowing the visiting medicalteam to know, in advance, what facili-ties, equipment and hospital access theycan expect when they arrive on-site,along with some key contact numbersand addresses.

What’s more, there’s more to a teamthan its players. Any doctor who hastravelled to a medium- or long-durationtournament may be able to endorse thethesis that the other members of thedelegation give as much work to themedical staff as the squad of players.Let’s imagine that one of the administra-tors or security staff is taken ill. Howmuch does the team doctor know abouthim or her? Hence the suggestion that,taking into full account all the confi-dentiality issues, some sort of medicalpassport accompanies every member ofthe travelling party so that the teamdoctor has foundations on which tobuild a response to illness or accident.

The UEFA teamLast but not least, Stockholm providedthe scenario for the first meeting of theUEFA Medical Committee, which hasbeen re-structured for the 2009-11 period. The committee’s chairman, Dr Michel D’Hooghe, welcomed fivenew members: Dr Ian Beasley from Eng-land, Dr José Henrique da Costa Jones of Portugal, Dr Ioannis Economides of Greece, Dr Andrea Ferretti of Italyand Dr Juan Carlos Miralles of Andorra.For the record, there were 16 items onthe agenda for their first get-together,covering many of the issues which madethe symposium such an enriching event.

Some of the other dishes on the Stock-holm smörgåsbord will undoubtedly appear in future issues…

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The UEFA Medical Committee

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Prof. Mats Börjesson, member of the Swedish FA’s medical committee


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Today, professional football is a result-driven industry where winning is the science of being totally prepared. JW Orchard is among those to have sug-gested that “the importance of med-ical/sports science staff in overall teamsuccess may be currently undervalued.”

Sports and medical science can createan understanding of training impactthrough the quantification of trainingloads and advise in the design of indi-vidualised multidisciplinary preparationprogrammes (physical, nutritional, psy-chological and technical), taking intoconsideration inter-individual variabilityand adaptation capacities. Planned and structured interventions can min-imise the incidence of injury and illness,

The high-tempo of the modern game,in addition to an increase in the num-ber of matches per season,is placing increasing physical and mental de-mands on the player. The speed of playand power exhibited by the player isgreater than ever before. An EnglishPremier League game was recently described as “an intense athletic experi-ence”. In the last ten years, statisticshave shown that, at the highest level,players in all positions now record moreoverall and high-speed distance totalsthan ever before.

On average, 16 of the 2008/09 UEFAChampions League teams had 230training sessions and 59 matches overthe season. This equated to 23 trainingsessions and 5.8 matches per monthwith an average 4:1 training/match ratio. In 2007/08, Glasgow Rangers hada 68-game campaign lasting from 31 July to 24 May, with an average of

increasing the availability of players for training and selection, and assist inestablishing a player’s “readiness toperform”. Adopting a systematic “sci-entific” approach to performance issues has the capacity to inform andenhance decision-making, improvegame understanding and positively affect risk management. Such insightshave the potential to positively influ-ence both the coaching process and resultant coaching behaviours.

SCIENCE – MAKING A DIFFERENCE INMODERN FOOTBALL?

Dr Paul Balsom

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Glasgow Rangers (Kyle Lafferty, in blue, pictured here in the Scottish Cup Final against Jackie McNamara of Falkirk) have a packed programme.

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During the symposium in Stockholm, Paul Balsom twiceappeared on stage alongside his former ‘boss’, LarsLagerbäck, head coach of the Swedish national team forover a decade. The first time was to discuss the importanceand the mechanisms of the ‘team behind the team’. Duringthe second, dedicated to ‘the future of football’, Paul, to his credit, had only a momentary expression of panic, whenasked to summarise, in two minutes, the role of science inthe future of top-level football. Afterwards, we offered Paulthe possibility to be more expansive on the pages ofMedicine Matters. This is the result…

BY DR PAUL BALSOM, PERFORMANCE MANAGER AT THE SWEDISH FOOTBALL ASSOCIATIONAND HEAD OF SPORTS SCIENCE AT LEICESTER CITY FC, IN COLLABORATION WITH GARY PHILLIPS, HEAD OF EXERCISE SCIENCE AT THE FOOTBALL ASSOCIATION


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4.4 days between matches. If five inter-national breaks totalling 59 days are excluded, the average was 3.8 days between matches. In the final month ofthe season, they played 9 games in 24 days. Add to this the confoundingvariation in kick-off times (from 12.00to 20.45) and it was hypothesised that the amount of travel and number of international players in their squadimpacted negatively on the club’s ability to achieve domestic and Euro-pean performance goals.

In response to these trends, the physi-cal development of the modern foot-baller has needed to adapt. Higher lev-els of strength and power are requiredto be more ‘explosive’ and increased resilience to physical impact, increasedaerobic and anaerobic power/capacitiesare necessary to produce intensive phys-ical efforts more frequently, and agreater ability to produce, reduce andstabilise force in a coordinated manneris imperative to execute complex techni-cal and locomotory actions at evenhigher speeds. Mike Forde, perform-ance director at Chelsea FC, noted thatthe primary aim of the support staff is to make sure that the players aretechnically, tactically, mentally andphysically prepared to cope with the demands of the modern game.

In the “team behind the team”, medicaland sports science practitioners are nowwell established at most professionalfootball clubs. In a recent interviewwith UEFA’s technical director, AndyRoxburgh, Sir Alex Ferguson was askedhow, in the last 25 years, the ingredi-ents for success had changed. “Theyhave changed in terms of the backup

required, particularly in the area of sports science. Medical information,nutrition and preparation of playersfor top-level games have reached another level.” Sir Alex’s current backroom staff at Manchester United includes five physios, a doctor, an optometrist, a podiatrist, a strengthcoach, three fitness coaches, twovideo analysts and two assistantcoaches.

In the UEFA injury study conducted byProf. Jan Ekstrand and his team dur-ing the 2008/09 season, the clubs withthe most favourable injury statisticswere asked to give subjective opinionsabout why they had such good results.Several highlighted the importance of good collaboration between themedical/sports science team and thetechnical staff.

Other reasons highlighted: the role ofassistant coaches in implementing asound mentality of training, rigour inadhering to prevention/treatmentprotocols, players who have minorcomplaints or imperfect condition be-ing allowed to rest, players monitoredbefore games to identify fatigue, the role of the fitness coach in help-ing to prevent muscle strains, individ-ualised programmes with focus on

nutrition, preparation and prevention,and important work by the psycholo-gist to achieve mental balance.

To be effective, sports science andmedical practitioners must be able toinfluence key decisions with respect to injury-reducing or performance-enhancing aspects such as trainingloads (duration and intensity), train-ing content (e.g. gym-based versus on-field activities), recovery strategies,training/team selection based on needs(considering the requirement to restplayers, etc). This is where the core val-ues, beliefs and leadership qualities of the modern-day coach become critical.

It can be argued that the job descrip-tion of the head coach of a modernprofessional football team can be compared to the CEO of a business,who commands overall responsibilityfor a company’s operations. Sir AlexFerguson puts his longevity down todeveloping management skills asmuch in common with running largecompanies as with work on the foot-ball pitch. He is no longer the one-manband who did everything. With a hundred players and staff under hiscontrol, he has become a master of overseeing a giant operation at aclub valued at £1 billion.

The medical symposium in Stockholm

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Sir Alex Ferguson and his assistant, Mike Phelan, have the supportof an extensive medical team atManchester United.


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“It would be impossible to work in thesame way as I did in 1986,” said Sir Alex.“It’s too big a beast now to be hands-onwith everything. Delegating is essential.I’ve learned at this level you need goodpeople around you. I trust them andrely on them. There must be about 40 people who report to me now, quiteapart from the players.”

Ric Charlesworth, in his book TheCoach: Managing for Success, writes “a manager must optimise athletes’ capacities with a training, learning andcounselling regime. His task is not sim-ply a scientific one for the subtleties.Nuances of coaching are best learned byexperience and wide consultation. The coach must absorb scientific dataand apply them to the best effect usingjudgement and finesse.”

Modern management demands the cre-ation and integration of an athlete-focused/coach-centred holistic, multidis-ciplinary support team to implement a support infrastructure which allowsfor the systematic development of tal-ent. The task is to develop and coordi-nate a programme of sports science andmedical services for players – its objec-tive to provide the right opportunities(facilities, training and competition) andsupport (sports medicine/science) forthe right people (coaches/athletes) atthe right time. When operating opti-mally, these support systems have thepotential to underpin high perform-ance, maximise the talent of the athleteand provide the coach with detailed information on individuals and thegroup in order to help them make moreinformed coaching decisions.

The growth in the number of medicaland sports science practitioners in foot-ball has led to the emergence of a ‘scientific coordinator’ or ‘performancemanager’. A good relationship with the

At Chelsea, Carlo Ancelotti has a scientific coordinator to help him to prepare his team.

head coach is essential for this role tobe successful. All information gatheredby the medical and sports science prac-titioners is filtered in order to providethe coach with an executive report.Bruno Demichelis, the scientific coordi-nator at Chelsea FC, describes his roleas “assisting the coach in order tocoor dinate all the activities that sup-port the team and individual players tohelp them reach their highest perform-ance levels.” He is one of three assis-tant managers, alongside Ray Wilkinsand Paul Clement, a trend envisagedto become more prevalent in theforthcoming decade and crucial to ensure that programmes are devel-

oped on objective decision-makingrather than subjective opinion. The per-formance decisions made by the sup-port team need professional accept-ance. Key decisions such as when theplayer can return, should NOT betainted by the opinion of the coach.

Is sports and medical science having animpact on the game today? Undoubt-edly yes. Greater resourcing, integrationand application of the multidisciplinaryapproach will see the support team pro-vide greater performance insights astechnology develops and both the inter-pretation and communication of knowl-edge improves.

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Stopping the game Law 5 states that a referee should stopthe match if, in his/her opinion, aplayer is seriously injured and ensurethat the player is removed from thefield of play. This is down to a referee’sindividual interpretation and ability todiscriminate between serious and non-serious injury. This is not always easy.

The abiding principle in medical prac-tice is ‘first: do no harm’. Delayingtreatment may cause harm. Refereeshave a duty to permit medical staff onthe field as soon as a player’s need

for medical assistance is recognised.Beware the player who is not movingfollowing a challenge.

The cautioning of a player should not be the priority: the medical staffneed to be called on first.

There must also be an understandingthat observed life-threatening orlimb-threatening injury warrants im-mediate access. There are caseswhere the medical profession wouldrespectfully ask the referee not to be too pedantic about ‘entering thefield of play without permission’.

Serious injuryWhat should be considered a ‘seriousinjury’? Evidently, players who areunconscious, have impaired breath-ing or are bleeding severely. Theseare ‘time-critical’ injuries which require immediate medical atten-tion. Fractures, dislocations and head or spinal injuries similarly needprompt attention.

Severe bleeding, if not controlledquickly, will cause a player to go intoshock and possibly lose consciousness.The bleeding may also conceal a potentially serious open fracture ofthe lower leg. Those managing anopen wound must wear disposableprotective gloves. Bloodstained cloth-ing must be changed before a playeris allowed to return to play and anyblood on the field of play should be dispersed.

No head injury is trivial. Delayed in-jury response is potentially cata-strophic. It is important that refereesdo not measure severity only by un-consciousness. A player may sustain afractured skull or a spinal injury as a result of a blow to the head and yetremain conscious. But players whoare rendered unconscious, no matterhow short the timeframe, should notbe allowed to return to the match.The use of smelling salts on uncon-scious players, which prompts a vio-lent neck movement, may result in spinal trauma. Referees should alsobe aware that the use of chewinggum entails a risk of choking or air-way compromise.

Manhandling players There is widespread misunderstand-ing that an unconscious or concussedplayer may have ‘swallowed histongue’ and must be immediatelymoved into the ‘recovery position’

MEDICAL STAFF ANDREFEREES

The presentation in Stockholm by Markus Merk highlightedthe need for collaboration between referees and medical staff in terms of assessing and treating injuries. It offered theperfect cue for Medicine Matters to feature an abridged version of an article by Mike Healy, head of medical educationat The Football Association, entitled:

Referees have a duty of care to theplayers and pre-game confirmationthat the playing conditions, the play-ing area, the ball and the player’sequipment comply with the laws, andare not a potential source of injury, aretestimony to this fact.

Pre-match briefingPre-match dialogue between refereeand medical staff can be useful to reviewthe protocol related to entering thefield of play and to ensure that any in-jury is managed efficiently and does notunduly delay the restart of the game.

The referee checks to see how badly the player is injured.

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Teaming up to care for the players


(on their side with their head back).Both misconceptions need to be dis-pelled. Players do not swallow theirtongues; the relaxed tongue simply fallsback and obstructs the airway. An ob-structed airway can be managed by appropriate head positioning. Puttinga player in the ‘recovery position’ doesnot mean a player will recover! What’smore, moving an injured player mayunwittingly cause them further harm.

Referees should avoid touching ormoving an injured player and shoulddiscourage manhandling by team-mates before being medically assessed,‘normal’ breathing is confirmed, andpotential spinal injury excluded (therisk could be permanent paralysis of the player). The referee has a dutyto hasten the arrival of the medicalstaff responsible for the ‘duty of care’.

On-field management of injured players A referee should allow an injuredplayer to be medically assessed beforebeing removed from the field of play.To do this, referees need to be able to differentiate between the ‘assess-ment’ and ‘treatment’ of an injury.

The standard ‘on-field’ musculo-skele-tal injury assessment process has thefollowing stages: i) questioning theplayer, confirming responsiveness andthe site of injury; ii) a look at the siteof the injury; iii) gentle palpationaround the area of the injury; iv) activemovement of the injured/involvedjoint by the player; v) passive move-ment of the injured/involved joint bythe physiotherapist; and vi) resistancetests of the muscles working over theinjured/involved joint. The process isdesigned to assess the integrity of thebony structures, ligaments, musclesand tendons and to confirm the suit-

ability of a player to return to play.Treatment is only applied once this process is complete. Serious injuries clearly take longer to assess.

Referees sometimes fail to appreciatethat a physiotherapist’s use of handsdoes not necessarily constitute treat-ment. And – a point which also appliesto some of the other issues raised –referee observers should not pre-judgea delay as poor referee control.

On-field treatmentInjury treatment is considered to beany intervention, e.g. ice applicationor strapping of a joint, which takesplace after an injured player has beenassessed. In most instances it is safe tohave the player leave the field of play.However, in cases of serious injury, a player should not be moved untilpre-hospital treatment has been administered and the injury/conditionis stabilised.

The emergency management of aplayer who is unconscious, not breath-ing normally or has a suspected or obvious spinal injury or fracture, maytake several minutes. Airway manage-ment, oxygen administration, immo-bilisation of the spine and fracture sta-bilisation all take time. This is wherethe medical staff are grateful for thereferee’s patience.

Removal of injured players The referee is responsible for ensur-ing that an injured player is safely removed from the field of play, butthe ultimate decision on removal andthe method of removal is for medicalstaff alone. The referee should beready to accept expert opinion ratherthan harass medical staff or insist thata player gets onto a stretcher. Playerswho are able to walk off the pitch

should be allowed to do so, as it is apart of a functional assessment process. Stretcher-bearers, typically called on atthe same time as the medical staff,need to understand their supportingrole. They must not intervene, man-handle players or attempt to put themon a stretcher until asked to do so bythe medical staff.

Conclusion There are many ways in which a ref-eree can safeguard the health of theplayers and contribute to the quality ofmedical care for an injured player. Thedefault position should be that Law 18,‘the law of common sense’, should pre-vail and that referees, in partnershipwith the medical staff, should alwaysact in the best interests of the playersand ensure that prompt medical atten-tion is permitted and administered.

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If the injury looks serious, the referee allows the doctor onto the field.

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Arsenal’s goalkeeper Vito Mannone receives treatment on the field during a Premier Leaguematch against West Ham.


Even though Germany is one of thecontinent’s frontrunners, organisedwomen’s football is still a relativelyyoung discipline. The first women’sleague match in Germany, for in-stance, was not played until 1990 and,in a majority of other member associ-ations, league football is an even

more recent phenomenon – a factwhich may have a bearing on certainmedical parameters. This means thatgrowth rates are more spectacularthan in the men’s game. In Germany,the audience in Stockholm was told,women’s football experienced agrowth of 21.27% between 2000 and

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2008, whereas the growth rate in themasculine game was 2.45%. This sortof statistic, even though the figuresvary considerably from country to country, is a clear indicator of therapidly increasing need to provideproper medical care for female play-ers. Dr Schneider’s presentation onthe specificities of women’s footballwas therefore thought-provoking.

He started by examining workloads. A survey among German nationalteam players revealed that they playedbetween 22 and 45 club matches a season (at an average of 32.5) plus between 1 and 20 for national teams (at an average of 10.6). The averagematch-play workload was therefore 43 games and could, in an extremecase, stretch as far as 65. Training unitsranged from 4 to 12 per week at an average of 6.4 – all of which adds upto figures easily comparable with phys-ical loadings in the men’s game.

In terms of workload during matches,Dr Schneider commented that analysisbased on the German national teamagainst top-class opposition revealedan average distance covered of 10,507metres, with midfielders averaging11,784 – again, figures comparablewith the men’s game. However, run-

One of the presentations made during the symposium in Stockholm was by Dr Ulrich Schneider, medical consultant to the German national team which, as theirrivals will not wish to be reminded, is THE dominant forcein European women’s football – a fact highlighted bytheir fifth successive victory at the Women’s EURO 2009finals staged in Finland. In medical terms, the fact thatGermany has set benchmarks on the field of play is possibly less relevant than the figure of over 1 millionregistered female players, which provides a broad base for data gathering and analysis.

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Dr Magnus Forssblad, chairman of the Swedish FA’s medical committee,

addresses the symposium.


ning patterns differ substantially, withonly 260 metres covered at sprintspeed (179 metres at speeds between21 and 24km/h and 81 at speeds of24+), and a further 765 metres coveredin the 17–21km/h speed range. High-speed running therefore represents0.77 of the total distance covered.

Interestingly, comparisons were madebetween the two members of an at-tacking partnership. One covered11,115 metres during the game, 372 ofthem (3.3%) at 21km/h or more. Theother ran a lower distance (10,466 metres) but covered 494 (4.7%) athigh speed. Comparing top-level per-formances, the distances covered atsprint speed in men’s football are approximately 50% higher than at theelite end of the women’s game.

Having said that, the figures pre-sented by Dr Schneider in Stockholmindicated that performance levels inthe women’s game are increasing. Between 2006 and 2009, the meantime for explosive sprinting over 5 me-tres decreased from 1.11 to 1.05 sec-onds (compared with 0.95 in the men’sgame). Over 30 metres, the time has been lowered from 4.45 to 4.35.

Recent studies of heart rates duringelite women’s games have demon-strated a high degree of consistencyover the 90 minutes, with readingsreaching 87% of maximum values.

Studies have also revealed that anae -mia is an issue to be addressed in themedical care of female players, withHb and Ferritin readings – even amongnational team players – quite oftendropping to levels which are consider-ably below normal and which canplace considerable restrictions on per-formance.

On the other hand, Dr Schneider revealed that the sort of eating disor-ders or menstrual dysfunctions preva-lent in other sporting disciplines arenot endemic to the footballing popu-lation. Indeed, the percentages arethree or four times lower – and sub-stantially less frequent than in societyat large. The anthropometric data hepresented indicated that the under-20sare now taller and heavier than their‘senior’ team-mates – which made for some interesting comparisons with data related to the squads at the 2009 European Women’s Champi-

onship final round in Finland, wherethe average height was 169cm andthe weight 62kg.

A few minutes before Ulrich Schnei-der stepped on to the stage in Stock-holm, Magnus Forssblad, chairman ofthe Swedish FA’s medical committee,national team doctor and orthopaedicsurgeon, had asked a rhetorical ques-tion with regard to medical skills andethics. “We might be skilled, inter-ested and capable surgeons when per-forming ACL reconstructions,” he said,“using high-tech methods, latest graft

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Studies have demonstrated the high level of consistent effort of Germany’s women’s team.

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Prof. Jan Ekstrand is in charge of UEFA’s injury study.


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choice and increasing percentages of double-bundle technique, but canwe honestly recommend a 15-year-oldgirl to return to football?”

The italics don’t reflect a change ofMagnus Forssblad’s tone, but rather anunspoken question: why had he cho-sen a 15-year-old girl as an example?Dr Schneider was to throw light on it by referring to the high incidence ofanterior cruciate ligament injuries inwomen’s football. A season-long studyin the German league had produced a figure of 2.2 ACL ruptures per 1,000 hours of match play and a sur-vey among national team players revealed that 23% had suffered anACL rupture in the past – most of them at tender ages.

This dovetailed with a survey con-ducted by UEFA during the Women’sEURO 2009 as part of the ongoing injury research project. A study basedon 10 of the 12 squads revealed that4.9 players per team had suffered an ACL rupture – representing 22% of all the players at the finals. For the record, there was one ACL rup-ture during the tournament – and itoccurred during training.

By contrast, a similar study among the eight finalists at the Women’s Under-19 Championship final round played in Belarus a month before the tournament in Finland had revealed an average of 0.5 persquad (3% of the total).

Magnus Forssblad, however, referredto data collected between 2005 and2010, which revealed a contrast be-tween patterns of men’s and women’sACL ruptures. Whereas the ‘peak period’ for the men was between theages of 20-25, the age group most

at risk in women’s football is between 15 and 20, with an absolute peak be-tween 17 and 19. Dr Schneider offeredplausible explanations for the high incidence of ACL ruptures: anatomicalfactors (such as increased Q-angle,smaller intercondylar notch in the femur), hormonal influences on kneejoint stability, or muscle strength andneuromuscular activation patterns(e.g. hamstring to quadriceps ratio).

However, statistics related to othertypes of injury hint at an evolutionwithin women’s football. Dr Schneiderhad referred to studies which revealeda peak of injuries at under-15 level,which then dropped steadily until theage of 19. The same studies showed an approximate equilibrium betweencontact and non-contact injuries (52 to 48%), with 52.6% of the non-contact variety occurring during run-ning (30.5%) or abrupt changes of direction (22.1%) – followed by shoot-ing (15.8%), jumping (11.6%) or im-pact from the ball (10.5%), with theremaining 9.5% down to various other types of incident. Of the con-tact injuries, 70.6% were the result of a tackle deemed to be legitimate,22.5% were derived from foul play and 6.9% were due to collisions.

One of the salient features was thatcontusions provided 27.3% of thigh injuries, 13% of those related to theknee and 9.3% of the ankle injuries.“The traditional notion,” commentedProfessor Jan Ekstrand, “is based onmass and velocity. So the parametersof the men’s game are more likely

to produce fractures, whereas thedoctor working with a women’s teamis more likely to deal with contusions.But that might be changing.”

His suspicion can be backed by figuresfrom the Women’s EURO 2009. At the2005 finals in England, there had beenno fractures. In Finland, the numberof contusions was lower (six), butthere were four fractures – hintingthat the mass and velocity equation at the top end of the women’s gamemight be evolving. Contusions and fractures jointly accounted for36% of the injuries.

UEFA’s injury study conducted in Fin-land provided positive information inthat the tournament registered a clear trend towards lower incidences

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Women’s youth teams are also monitored closely from a medical point of view.

Sweden v England in the Women’sEURO 2009, which was the subject of

a medical study


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of injury. During the 19-day, 25-matchevent, 27 injuries were recorded – 19 of them during match play. Thehighest injury rate was recorded dur-ing the 18-match group stage, thoughthe three severe injuries (entailing anabsence of four weeks or more) wereall sustained during the knockoutphase of the tournament – and allthree were knee-joint lesions in non-contact situations. Of the other 24, 15 (55% of the total) entailed absencesof up to three days and only six resulted in absence of over one week. A total of 85% of the injuries weretraumatic. Another salient feature wasthat, whereas 20–25% of injuries in themen’s game affect the thigh, thewomen’s tournament registered only11% and of minimal severity.

In injury studies, ‘down’ is a goodword. At the Women’s EURO 2009,down went the incidence of severe injuries (2.5 per 1,000 hours comparedwith 5.6 at EURO 2005 and 9.5 at the men’s EURO 2008) and down wentthe overall incidence of injury (22 per1,000 hours of match play comparedwith 36 at EURO 2005).

The incidence of injury in training wasalso very low, at 3.3 per 1,000 hours,yet provided 30% of all the tourna-ment’s injuries and 38% of those whichentailed an absence of over a week. In this sector, comparisons with 2005are dangerous, given that the finals inEngland were played in June, whereasthe event in Finland was staged in late August / early September. The2009 training schedules had high rest-and-recovery components and thenumber of sessions during the groupphase ranged from three to eight –something logical bearing in mind thatsome contestants were in mid-season,others in pre-season.

At the same time, UEFA’s injury studiesat the finals of its Women’s Under-19Championships have also revealed an interesting pattern. After a slight upturn at the 2007 finals in Iceland,the incidence of injury has headedsteadily downwards.

It is dangerous to jump to conclusions.But it could be legitimate to debatewhether one of the statistics presentedby Dr Schneider might be part of theexplanation. He pointed out that, in the year 2000 in Germany, 25.3% of the registered female players were under-16s. By 2008, this had risen to 32.5%.

It could be argued that if girls areplaying football from earlier ages,their limbs receive a more completefootballing education than those whocome into the game at – literally andfiguratively – secondary educationstages, with the extra years of training

and playing helping to generate hardened tissues. Projecting into the future, Dr Schneider suggested inStockholm that female players willneed to be equipped for more high-intensity running and that preventivestrategies aimed at reducing the inci-dence of knee and ankle injuries in the higher-risk age groups will need to include specific training on aspects such as proprioceptive coordi-native exercising, lower-extremitylanding skills, plyometrics and the im-provement of muscle balance.

Bearing in mind that Germany is atthe top of the women’s ladder, the advice is of special interest to nationalassociations on the rungs below them,where girls may be starting to playtheir football at later ages, and wheredoctors have a role to play in helpingthem to avoid the physical pitfallswhich, in recent years, have becomeapparent in the women’s game.

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The Danish women’s team in training during the Women’s EURO 2009

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Dr Ulrich Schneider, medical consultant to the Germanwomen’s national team


UEFARoute de Genève 46CH-1260 NyonSwitzerlandPhone +41 848 00 27 27Fax +41 22 707 27 34uefa.com

Union des associationseuropéennes de football


MEDICINE - UEFA · 2015-04-10 · MEDICINE MATTERS/3 EDITORIAL It was also a good idea to mix...

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