The Football Association Medical Research Programme: an audit of injuries in professional football - analysis of preseason injuries

C Woods, R Hawkins, M Hulse and A Hodson

British Journal of Sports Medicine

2002, Vol 36, page 436-441

Recently published research in the British Journal of Sports Medicine has highlighted the occurrence of injuries in English professional soccer during the pre-season training period. Injury data was collected by medical staff at 91 professional soccer clubs and analysed by the full time research physiotherapists at the English Football Association. In keeping with many previous studies on soccer injury epidemiology, the researchers found that in the two years of the study, 17% of all injuries (1025 of 6030 injuries) occurred during the pre-season training; this led the authors to analyse pre-season injuries in more depth. The pre-season period in English professional football lasts roughly from early July to mid August. It is the fitness rebuilding period of training and, as such, is physically demanding. As it follows a summer lay-off, the switch from relative inactivity to demanding work may lead to injuries due to insufficient adaptation.

The data was returned via a postal questionnaire method, between the 1997-98 and 1998-99 English football seasons, with return rates of 87% and 76% respectively for each season. This represents a very good response rate for this type of study. One flaw in the study is the definition of the pre-season period. The period is not clearly defined, but the data used by the authors shows that the month of July was classified as 'pre-season'. However, each team will have returned to training at a different date; some during the first week in July and others during the second week in July. In addition, elite players who participated in the 1998 World Cup finals may have been given permission to return to their clubs in late July. This may mean that the authors' definition of pre-season is inappropriate. Furthermore, if the competitive season begins in the first or second week of August, then two weeks of 'pre-season' injury data is not classified as such, leading to an underestimation of the true injury level.

The volume of injury data collected is impressive, but the ambitious design means the size of the study leads to further methodological flaws. Firstly, the researchers are reliant on the injury recording and interpretation of the individual medical staff at each of the ninety-one participating clubs. Each of these medical staff may have a different interpretation of an injury, based on their level of training and varying professional background. For example, while many of the medical personnel at Premiership clubs are Chartered Physiotherapists with post-graduate qualifications in sports medicine, the same is often not true of those personnel working at Football League clubs, where the level of training is often limited to a four week residential course organised by the Football Association. The authors do not provide details of any reliability testing between data collectors and it appears that this problem has not been addressed.

Woods et al established that tendon related injuries were more prevalent during the pre-season period, when compared with the competitive season, with 32% of Achilles related injuries being sustained during the pre-season period. Of these, 94% were classified as either tendonitis or paratendonitis. This would suggest a very low incidence of Achilles tendonosis, contrary to recent studies on tendon dysfunction. It would appear that either English soccer players, unlike other professional athletes, are seemingly immune to Achilles tendonosis, or the diagnostic skills of the data collectors are somewhat empirical. This may be due to the varying levels of professional qualification mentioned above and, consequently, casts a major doubt on the reliability of the data presented in this study.

Another variable not addressed by the authors is the differing demands on players of different levels. For example, the preparation and playing schedule for a player at a Premiership club that also competes in the UEFA Champions League is different from a player whose team is in the lower half of the Premiership, and very different from the player who plays for a club in the English Third Division. The authors have not attempted to analyse the data separately to take this into account. Anyone who observes English soccer at its different levels will conclude that the authors are not comparing like with like. This problem is further compounded by the fact that activity and exposure data was not examined by the authors, meaning the true risk of an injury cannot be determined. Indeed, this could be the biggest flaw in this well-meaning project, as it does not allow the reader to ascertain the true injury incidence based on matches played and training hours.

Despite its poor scientific rigour, this study received a high level of media attention due to the fact that it was funded by the Professional Footballer's Association and undertaken by the Football Association Medical Education Centre. Unfortunately, the main points disseminated by the media were, firstly, that the ground condition was dry in 70% of preseason injuries. This says more about the typical English summer (July) and nothing can be inferred from this regarding injuries. The second major point picked up by the media was that football boots provide poor support and may predispose a player to injury. What would the alternative be? To quote the authors on the role of football boots on injury, "…their design may contribute to injury..." and, incredibly, "…Footballers often purchase new boots at the start of pre-season without considering the most suitable boot for their foot type". To think that elite level players use one pair of boots in a season demonstrates the author's poor understanding of what goes on in a professional football club. Indeed, many elite level players wear a new pair of boots for each Premiership match.

Despite its good intentions, the methodological flaws within this study mean that it contributes little to the knowledge base on soccer injury epidemiology. Existing, more rigorous studies on the incidence of soccer injuries have already established injury patterns and linked these to specific playing activities. Perhaps future studies may have less ambitious objectives and provide more reliable data that is clinically relevant to practitioners who care for players at different levels.

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