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To determine the level of pre‐employment, pre‐season, and post‐injury medical evaluation of players undertaken within UK professional team sports.
A postal, whole population survey.
Elite professional sports teams in England.
Six groups comprising the following clubs: professional football (Premiership, 15 of 20; Championship, 22 of 24), rugby union (Premiership, 9 of 12; Division 1, 11 of 14), rugby league (Super League, 6 of 11) and cricket (County, 12 of 18).
Number (percentage) of clubs recording players' medical history and undertaking medical examinations of players' cardiovascular, respiratory, neurological, and musculoskeletal systems at pre‐employment, pre‐season and post‐injury.
The overall response to the survey was 74%, with a range from 55% to 92% among groups. Almost 90% of football (Premiership and Championship) and rugby union (Premiership) clubs took a pre‐employment history of players' general health, cardiovascular, respiratory, neurological, and musculoskeletal systems, but fewer than 50% of cricket and rugby union (Division 1) clubs recorded a history. The majority of football (Premiership and Championship) and rugby union (Premiership) clubs implemented both cardiovascular and musculoskeletal examinations of players before employment. Fewer than 25% of clubs in any of the groups implemented neurological examinations of players at pre‐employment, although 100% of rugby union (Premiership) and rugby league clubs implemented neurological testing during pre‐season.
None of the sports implemented best practice guidelines for the preparticipation evaluation of players at all stages of their employment. Departures from best practice guidelines and differences in practices between clubs within the same sport leave club physicians vulnerable if their players sustain injuries or ill health conditions that could have been identified and avoided through the implementation of a preparticipation examination.
Employers in the United Kingdom are required by law to inform current and potential employees about the risks to their health and safety arising from work activities1 and, where the activities require a minimum level of health, to implement medical assessments in order to confirm employees' fitness for work.2 For some occupations—such as pilots3 and divers4—specific assessments are embodied within UK legislation. In the case of professional team sports, where the risks of injury are generally much higher than those experienced in industry,5 there are no legal requirements for pre‐employment, pre‐season, or post‐injury medical assessment of players. The deaths of several elite athletes from sudden cardiac arrest6 have focused the attention of sports governing bodies on the management of sports related health risks. Some international sports governing bodies, such as Fédération Internationale de Football Association (FIFA), do provide guidance on medical evaluation7 and for some specific competitions, such as the FIFA 2006 World Cup, they insist that players undergo medical assessments before they are allowed to compete.8 Guidance on preparticipation evaluation (PPE) for athletes in the United Kingdom is limited, although the national governing bodies for football9 and rugby league10 advocate cardiovascular and musculoskeletal screening for youth players, and the governing body for rugby union11 has a concussion management programme for elite players that embodies pre‐season and post‐injury neuropsychological assessments.
There is some evidence to suggest that intrinsic factors—such as previous injury,12,13 malalignment,14 muscle tightness and weakness,14 and some heart conditions15—create a greater risk of injury or ill health for athletes. In most professional team sports, effective management of these risks is based on a mixed strategy of injury prevention, treatment, and rehabilitation.16 However, the short and medium term medical and financial consequences of injury for professional players and their clubs mean that prevention of injury rather than treatment is normally the preferred option.17 The core element of most injury prevention programmes is the identification of players' intrinsic risk factors16,18,19,20 coupled with the development of appropriate control measures that will reduce the incidence of injury.16
Corrado et al21 claimed that the introduction of compulsory preparticipation cardiovascular screening in Italy significantly reduced the incidence of sudden cardiac death among competitive athletes, although other investigators have questioned the validity of this conclusion.22 Because preparticipation screening for cardiovascular anomalies is fallible, Basilico15 recommended ongoing observation of athletes following the initial assessment and, where symptoms developed, implementation of further evaluation including a complete physical examination and an ECG. Preparticipation examinations for neurological problems such as concussion are extremely difficult, as most concussions recover fully and leave no residual indicators. In addition, concussions sustained in contact and collision sports may simply reflect an athlete's level of exposure to the sport rather than an underlying intrinsic risk factor.23 For this reason, the number of concussive events alone does not provide sufficient evidence on which to exclude an athlete from future involvement in sport. McCrory23 suggested using a detailed baseline assessment to identify and record players' histories of overt and occult concussive events, while Aubry et al24 recommended pre‐season neuropsychological examinations in order to provide useful benchmarks for players' during post‐concussion recovery evaluation.
Ekstrand14 considered that a history of previous injuries and a full pre‐season examination of mechanical and functional instability, range of movement, malalignment, and muscle strength was required to identify musculoskeletal risk factors. Garrick25 argued that generally the history of players' musculoskeletal systems provided a more sensitive screening tool than a physical examination. Clearly, previous injuries to the musculoskeletal system per se would not provide a valid reason for excluding a professional athlete from further involvement in sport, as most athletes sustain musculoskeletal injuries at some stage in their careers. Information obtained from a preparticipation musculoskeletal evaluation does, however, enable prehabilitation strategies26 and prophylactic taping27 to be prescribed in order to compensate for a player's muscle or joint weaknesses.
Although the benefits are equivocal,28 PPE remains the primary means whereby sports physicians can identify athletes with predisposing risk factors.29 The implementation or non‐implementation of PPE and the exclusion or non‐exclusion from competition of athletes identified with risk factors raises complex legal issues for clubs, physicians, and players,30 and the recommended strategy for sports physicians is therefore to adopt best practice guidelines.30 It has not proven possible, however, to reach universal agreement on the content of a PPE specifically designed for athletes, although the recommendations for medical history and cardiovascular, neurological, and musculoskeletal screening presented in the publication Preparticipation Physical Evaluation29 are generally accepted as the most informed guidance available.
While there have been extensive discussions about the composition and value of PPE, few studies have assessed the degree to which, or when, PPE is actually implemented within professional team sports. One study in the USA31 reviewed the implementation of cardiovascular screening in men's professional team sports (American football, baseball, basketball, ice hockey). The survey showed that 41% of clubs undertook pre‐employment cardiovascular screening and 100% undertook pre‐season cardiovascular screening. During the annual pre‐season screening, every club took players' personal and family cardiovascular histories and measured blood pressure, and 92% of the clubs obtained a resting ECG. In the United Kingdom, Batt et al17 commented on the screening practices at one Premiership football club but it was not possible to extrapolate their comments to other football clubs or to other team sports.
Our aim in the present study was to assess the extent to which pre‐employment, pre‐season, and post‐injury medical evaluations were used within the major professional men's team sports in the United Kingdom.
The sample population investigated within this study consisted of six separate whole population groups from the four most popular men's professional team sports in the United Kingdom: namely, football (Premiership), 20 clubs; football (Championship), 24 clubs; rugby union (Premiership), 12 clubs; rugby union (Division 1), 14 clubs; rugby league (Super League), 11 clubs; and cricket (Divisions 1 and 2), 18 clubs. The rugby league Super League comprised 12 teams; however, one team was based in France and it was therefore not appropriate to include this team in a study of United Kingdom practices. In cricket, 18 teams competed in two major competitions (County Championship, Pro40) each of which operated through two divisions. However, because the two competitions operated independently, some teams played in the higher division in one competition and in the lower division in the other and vice versa; for this reason, all cricket teams were combined in a single group for assessment.
The guidance provided in Preparticipation Physical Evaluation29 recommended that a medical evaluation should include an athlete's general medical history together with a history and physical examination of their cardiovascular, respiratory, neurological, and musculoskeletal systems. These recommendations provided the basis for evaluating which preparticipation tests the clubs adopted and when the tests were implemented within the six groups. The content and format of a draft questionnaire were assessed using a pilot study involving seven physiotherapists, one sports therapist, and one sports physician, who were not included in the main survey but who worked within a range of team sports; minor changes were made to the draft questionnaire before the content of the final version was confirmed (table 11).). Questionnaires, together with an addressed, prepaid reply envelope and a letter describing the purpose of the study, were distributed by post to named senior physiotherapists at every club included in the study between March and May 2006, as this time period encompassed the playing seasons of all the sports involved. Physiotherapists were asked to indicate on the questionnaire at which stages (pre‐employment, pre‐season, post‐injury) they obtained medical information and conducted examinations.
Responses to individual questions by each group are reported as the number and percentage of positive responses.
The number and percentage of questionnaires returned by each sample group (average 74%; range 55% to 92%) are summarised in table 22.. All football (Premiership and Championship), rugby union (Premiership), and rugby league clubs, and all but one of the cricket clubs, employed a full time physiotherapist. In contrast, only one rugby union (Division 1) club employed a full time physiotherapist. Table 33 shows the number and percentage of clubs within each group that took a history of players' general health, cardiovascular, respiratory, neurological, and musculoskeletal systems before employment. employment.TablesTables 4, 55,, and 6 summarise the numbers and percentages of clubs within each group that undertook medical assessment tests for players' cardiovascular, neurological, and musculoskeletal systems during pre‐employment, pre‐season, and post‐injury periods.
The overall response rate from the clubs was high, which provided confidence that the results obtained from the survey were indicative of the PPE practices of all clubs within each of the groups. A limitation of this study, as with the equivalent study undertaken in the USA,31 was that the data were self reported by club physiotherapists and the responses could not be verified independently.
Medical history is regarded as the most useful form of PPE.29 Almost 90% of football (Premiership and Championship) and rugby union (Premiership) clubs and over 50% of rugby league clubs took a pre‐employment history of players' general health, cardiovascular, respiratory, neurological, and musculoskeletal systems. On the other hand, generally fewer than 50% of cricket and rugby union (Division 1) clubs recorded players' medical history before employment. The high proportion of clubs in football (Premiership and Championship) and rugby union (Premiership) recording both family and players' histories of cardiovascular disease was similar to that reported by professional team sports in the USA.31 Fewer rugby union (Division 1) and cricket clubs took players' concussion history than was the case for football (Premiership and Championship), rugby union (Premiership), and rugby league clubs despite the recommendation from the Second International Conference on Concussion in Sport that detailed concussion histories were of value.32 The large difference in practices for neurological testing between rugby union's Premiership and Division 1 clubs is particularly surprising, as there is no evidence that there is a significant difference in concussion risk between the two divisions. Only one cricket club took a concussion history, which probably reflects the perceived non‐contact nature of cricket compared with the other sports.
Cardiovascular screening is probably the most important element of PPE because of the potential for sudden cardiac death among athletes with undiagnosed heart conditions who take part in high intensity sports.15,33 At the pre‐employment stage, football (Premiership and Championship) and rugby union (Premiership) clubs generally examined players; however, only one third of the rugby union (Premiership) clubs used ECG examinations, even though research implies that this is the most cost effective strategy.34 Fewer than 40% of rugby union (Division 1) and cricket clubs undertook any form of pre‐employment cardiovascular screening of players. During pre‐season, levels of cardiovascular screening of any type were generally below 50% for all groups, which contrasts strongly with the practices reported for professional team sports in the USA,31 where over 90% of clubs implemented blood pressure and ECG tests during their annual pre‐season evaluations. Post‐injury evaluations of the cardiovascular system were rarely employed by any of the groups.
Neuropsychological tests are recommended as a means of managing players' recovery from concussion.24 Although few clubs in any of the groups implemented cognitive tests at the pre‐employment stage, they were used by all rugby union (Premiership) and rugby league clubs during pre‐season evaluations to provide baseline data for monitoring players' recovery from concussion. In contrast, only a quarter of rugby union (Division 1) clubs used cognitive testing of players during pre‐season evaluation. Interestingly, some rugby union (Premiership) clubs did not use cognitive tests to assess recovery from concussive events, and some rugby union (Division 1) clubs used cognitive tests following concussion even though baseline data had not been collected during pre‐season. Cognitive tests were only used by a small number of football (Premiership and Championship) clubs, which is surprising considering that 11% of all injuries in football are reported to be concussions.35 Except in the football (Premiership and Championship) clubs at the pre‐employment stage, neurological sensory assessments, such as vision and hearing, were not widely used by any of the sports.
Generally, over 80% of football (Premiership and Championship), rugby union (Premiership), and rugby league clubs undertook an extensive range of pre‐employment musculoskeletal examinations, which is consistent with the situation reported previously for one Premiership football club.17 Few cricket and rugby union (Division 1) clubs undertook any pre‐employment musculoskeletal examinations of players. However, while all rugby league clubs continued with most of their musculoskeletal examinations through annual pre‐season examinations, fewer than 50% of football (Premiership and Championship) and rugby union (Premiership) clubs implemented pre‐season musculoskeletal examinations. In contrast, more cricket and rugby union (Division 1) clubs implemented musculoskeletal examinations during pre‐season than at pre‐employment. Rugby league was the only sport where post‐injury PPE was used by most clubs. The differences between the groups in the approach to musculoskeletal examinations probably reflect the levels of financial commitment involved in employing professional players within the different groups.17
A foreseeable risk of injury and ill health places a responsibility on employers to identify those employees at risk and to implement preventive measures that reduce the level of risk. A lack of resources and the costs involved are often cited as reasons for not implementing preparticipation screening for all athletes6; this argument, however, is not sustainable within professional sport. The guiding principle for protecting employees' health and safety in the United Kingdom is ‘so far as is reasonably practicable', while the risk management approach is based on the principle of proportionality, whereby control measures should be proportional to the risks involved.36 In professional team sports, the risks of injury are very much higher than those found in most other occupations.5 It is therefore proportional and reasonably practicable for employers in professional team sports to implement medical screening procedures in order to identify those athletes with intrinsic risk factors that may place them at a greater risk of injury or ill health. None of the sports in this study followed best practice guidelines for the medical evaluation of athletes at all stages of their employment. Departures from best practice guidelines and differences in practices between clubs within the same sport leave club physicians vulnerable if their players sustain injuries or ill health conditions that could have been identified and avoided through the implementation of a preparticipation examination. Finally, if physicians working within professional team sports do not lead the way in demonstrating the importance of PPE, it will prove extremely difficult for general practitioners, who are responsible for the health of the vast majority of athletes, to promote PPE as an essential prerequisite for a long lasting, healthy involvement in sport.
We would like to acknowledge the contributions made by Brian Harrison during the preparation of the questionnaire and by the physiotherapists who completed the questionnaire on preparticipation medical assessment procedures used within professional team sports.
PPE - preparticipation evaluation
Competing interests: None declared.