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1.  Efficacy of the FIFA 11+ Warm-Up Programme in Male Youth Football: A Cluster Randomised Controlled Trial 
The FIFA 11+ is a structured warm-up programme specially designed to prevent injuries among football players from age 14 years and above. However, studies to prove its efficacy are generally few and it is yet to be tested in male youth footballers and among African players. The purpose of the study was to examine the efficacy of the FIFA 11+ programme in reducing the risk of injuries among male youth football players of the Lagos Junior League. A cluster randomised controlled trial was conducted. All the 20 teams (414 players aged 14 -19 years) in the Premier League division were block-randomised into either an intervention (INT) or a control (CON) group. The INT group performed the FIFA 11+ exercises as warm-up during training sessions and the CON group performed usual warm-up. Participating teams were prospectively followed through an entire league season of 6 months in which they were visited every week to assess injured players for time-loss injuries in both groups. The primary outcomes were any injury to the players, injuries by type of exposure and injuries specific to the lower extremities. The secondary outcomes were injuries reported by body location, aetiology, mechanism and severity. In total, 130 injuries were recorded affecting 104 (25%) of the 416 players. Team and player compliance with the INT was 60% and 74% respectively. Based on the primary outcome measures of the study, the FIFA 11+ programme significantly reduced the overall rate of injury in the INT group by 41% [RR = 0.59 (95% CI: 0.40 – 0.86; p = 0.006)] and all lower extremity injuries by 48% [RR = 0.52 (95% CI: 0.34 – 0.82; p = 0.004)]. However, the rate of injury reduction based on secondary outcomes mostly did not reach the level of statistical significance. The FIFA 11+ programme is effective in reducing the rates of injuries in male youth football players.
Key pointsThe FIFA 11+ has only been tested in randomised controlled trials conducted on female youth football players; this study reports its efficacy in male youth football for the first timeThe FIFA 11+ programme significantly reduced the overall rate of injuries and lower extremity injuries in male youth football playersYouth football administrators in Africa and other parts of the world should pursue the implementation of the FIFA 11+ in order to minimize the incidence of injuries among players
PMCID: PMC3990886  PMID: 24790486
Injury prevention; neuromuscular training; FIFA; sports
2.  Time-Loss and Non–Time-Loss Injuries in Youth Football Players 
Journal of Athletic Training  2007;42(3):395-402.
Context: Estimates suggest that more than 5.5 million youths play football annually, and 28% of youth football players (age range = 5 to 14 years) are injured each year, resulting in more than 187 000 emergency room visits.
Objective: To analyze time-loss (TL) and non–time-loss (NTL) injury patterns across age groups in youth football players.
Design: Two-year observational cohort.
Setting: Two midwestern communities, including players from the fourth through eighth grades and between the ages of 9 and 14 years.
Patients or Other Participants: A total of 779 players participated, including 296 in grades 4 and 5; 203 in grade 6; 188 in grade 7; and 92 in grade 8. (Players in the fourth and fifth grades participated on the same teams, so we considered them as a single group.)
Main Outcome Measure(s): Injury frequencies and exposures were collected by certified athletic trainers present at each practice and game and used to calculate injury rates with 95% confidence intervals (CIs) for both TL and NTL injuries across age groups.
Results: A total of 474 injuries and 26 565 exposures were identified. Injuries were reported by 36.5% of the players, with 14.4% reporting more than 1 injury in a season. The overall injury rate per 1000 athlete-exposures (A-Es) was 17.8 (95% CI = 16.3, 19.5). The injury rate increased with each succeeding grade from 14.3 per 1000 A-Es (95% CI = 12.1, 16.9) in grades 4 and 5 to 21.7 per 1000 A-Es (95% CI = 17.2, 27.3) in grade 8. A total of 58.6% of all injuries were NTL. Non–time-loss injuries accounted for 70.1% of the injuries reported by fourth and fifth graders, 55.1% by sixth graders, 64.0% by seventh graders, and 33.8% by eighth graders. The cumulative NTL injury rate was 10.5 per 1000 A-Es (95% CI = 9.3, 11.8), and the TL injury rate was 7.4 per 1000 A-Es (95% CI = 6.4, 8.5).
Conclusions: Youth football players sustained more NTL injuries than TL injuries. We recommend that a first-aid–certified coach or league official be present at all games and practices.
PMCID: PMC1978461  PMID: 18059996
youth sports; epidemiology; injury incidence
3.  Selected Musculoskeletal and Performance Characteristics of Members of a Women's Professional Football Team: Application of a Pre-participation Examination 
Background
Although it is common practice to administer pre-participation examinations (PPE) of athletes prior to training, there are no clearly established formats. Elements integral to the PPE fall within the scope of physical therapist practice, and are often categorized as a form of primary prevention for musculoskeletal disorders as defined in the Guide to Physical Therapist Practice.
Purpose
The purpose of this study is to describe the design and implementation of a PPE for a women's professional (gridiron) football team. The results and findings from this PPE provide one of the first musculoskeletal profiles and information about selected physical characteristics from members of a female professional football team.
Methods
Players from the Kentucky Karma women's football team, a member of the National Women's Football League (NWFA), volunteered to participate in a PPE. Of twenty-five eligible team members, thirteen consented to participate. The PPE consisted of a health history questionnaire, a musculoskeletal screening, and a series of physical performance and agility tests.
Results
The players' average (± SD) age, height, weight, body mass index (BMI), and body fat percentage were 29.6 (± 5.6) yrs., 1.66 (± .05) m, 66.8 (± 12.6) kg, 24.1 (± 3.7), and 27.4 (± 6.6) %, respectively. Commonly reported injuries were similar to those reported in men's collegiate football.
Conclusion
This is one of the first papers to report on a model PPE for a women's professional football team. Future research is needed to establish a standard PPE, recognize common injuries, and develop prevention strategies unique to women's professional football.
PMCID: PMC2953349  PMID: 21509153
musculoskeletal screening; female athlete; performance testing
4.  Risk of injury in elite football played on artificial turf versus natural grass: a prospective two‐cohort study 
British Journal of Sports Medicine  2006;40(12):975-980.
Objective
To compare injury risk in elite football played on artificial turf compared with natural grass.
Design
Prospective two‐cohort study.
Setting
Male European elite football leagues.
Participants
290 players from 10 elite European clubs that had installed third‐generation artificial turf surfaces in 2003–4, and 202 players from the Swedish Premier League acting as a control group.
Main outcome measure
Injury incidence.
Results
The incidence of injury during training and match play did not differ between surfaces for the teams in the artificial turf cohort: 2.42 v 2.94 injuries/1000 training hours and 19.60 v 21.48 injuries/1000 match hours for artificial turf and grass respectively. The risk of ankle sprain was increased in matches on artificial turf compared with grass (4.83 v 2.66 injuries/1000 match hours; rate ratio 1.81, 95% confidence interval 1.00 to 3.28). No difference in injury severity was seen between surfaces. Compared with the control cohort who played home games on natural grass, teams in the artificial turf cohort had a lower injury incidence during match play (15.26 v 23.08 injuries/1000 match hours; rate ratio 0.66, 95% confidence interval 0.48 to 0.91).
Conclusions
No evidence of a greater risk of injury was found when football was played on artificial turf compared with natural grass. The higher incidence of ankle sprain on artificial turf warrants further attention, although this result should be interpreted with caution as the number of ankle sprains was low.
doi:10.1136/bjsm.2006.027623
PMCID: PMC2577464  PMID: 16990444
injuries; football; surface properties; soccer; artificial turf
5.  Australian rural football club leaders as mental health advocates: an investigation of the impact of the Coach the Coach project 
Background
Mental ill health, especially depression, is recognised as an important health concern, potentially with greater impact in rural communities. This paper reports on a project, Coach the Coach, in which Australian rural football clubs were the setting and football coaches the leaders in providing greater mental health awareness and capacity to support early help seeking behaviour among young males experiencing mental health difficulties, especially depression. Coaches and other football club leaders were provided with Mental Health First Aid (MHFA) training.
Method
Pre-post measures of the ability of those club leaders undertaking mental health training to recognise depression and schizophrenia and of their knowledge of evidence supported treatment options, and confidence in responding to mental health difficulties were obtained using a questionnaire. This was supplemented by focus group interviews. Pre-post questionnaire data from players in participating football clubs was used to investigate attitudes to depression, treatment options and ability to recognise depression from a clinical scenario. Key project stakeholders were also interviewed.
Results
Club leaders (n = 36) who were trained in MHFA and club players (n = 275) who were not trained, participated in this evaluation. More than 50% of club leaders who undertook the training showed increased capacity to recognise mental illness and 66% reported increased confidence to respond to mental health difficulties in others. They reported that this training built upon their existing skills, fulfilled their perceived social responsibilities and empowered them. Indirect benefit to club players from this approach seemed limited as minimal changes in attitudes were reported by players. Key stakeholders regarded the project as valuable.
Conclusions
Rural football clubs appear to be appropriate social structures to promote rural mental health awareness. Club leaders, including many coaches, benefit from MHFA training, reporting increased skills and confidence. Benefit to club players from this approach was less obvious. However, the generally positive findings of this study suggest further research in this area is desirable.
doi:10.1186/1752-4458-4-10
PMCID: PMC2889859  PMID: 20482809
6.  Injuries in Eleven Selected Sports 
All the clubs for 10 sports in the four northern counties were surveyed for injuries for a whole playing season and a 50% sample of the badminton clubs were surveyed in the same way. After the two types of football, hockey comes third in the injury league with women getting injured mostly in the legs, but men in the upper part of the body. Protective padding for hockey players' legs is suggested. Finger injuries and occasional concussion are characteristics of cricket and sprains and strains of badminton. The severity rate in fencing was low with an occasional superficial cut. Cycling was safe, but when an accident did happen it usually produced multiple abrasions as can be readily understood by anyone who has fallen off a bicycle. Boxing and judo did not produce many injuries, but when they did, they were severe, and needed a relatively long time (on average 3 weeks) off sport. But, paradoxically the medical attention which they attracted was better than that attracted by the minor injuries of the other sports. Rowing and swimming were both very safe sports, notwithstanding the potentially hazardous nature of water. The injuries in sub-aquatic activities seemed to depend upon the club rather than upon the sport itself, which suggests that rather more careful supervision may sometimes be necessary.
The range of injury produced by sport is so wide—from a bruise to a brain injury—that it is difficult to avoid the conclusion that the hospital accident room is the right place to receive the injured player in the first instance. From here he can, if necessary, be routed to another department for more specialized treatment.
Introducing more first aid training into sport, at, perhaps, the level of club officials, players themselves, and in addition, regular supporters will be the most useful steps which can be taken in the management of sports injuries.
PMCID: PMC1859352
7.  Hip abduction weakness in elite junior footballers is common but easy to correct quickly: a prospective sports team cohort based study 
Background
Hip abduction weakness has never been documented on a population basis as a common finding in a healthy group of athletes and would not normally be found in an elite adolescent athlete. This study aimed to show that hip abduction weakness not only occurs in this group but also is common and easy to correct with an unsupervised home based program.
Methods
A prospective sports team cohort based study was performed with thirty elite adolescent under-17 Australian Rules Footballers in the Australian Institute of Sport/Australian Football League Under-17 training academy. The players had their hip abduction performance assessed and were then instructed in a hip abduction muscle training exercise. This was performed on a daily basis for two months and then they were reassessed.
Results
The results showed 14 of 28 athletes who completed the protocol had marked weakness or a side-to-side difference of more than 25% at baseline.
Two months later ten players recorded an improvement of ≥ 80% in their recorded scores. The mean muscle performance on the right side improved from 151 Newton (N) to 202 N (p<0.001) while on the left, the recorded results improved from 158 N to 223 N (p<0.001).
Conclusions
The baseline values show widespread profound deficiencies in hip abduction performance not previously reported. Very large performance increases can be achieved, unsupervised, in a short period of time to potentially allow large clinically significant gains. This assessment should be an integral part of preparticipation screening and assessed in those with lower limb injuries. This particular exercise should be used clinically and more research is needed to determine its injury prevention and performance enhancement implications.
doi:10.1186/1758-2555-4-37
PMCID: PMC3500216  PMID: 23031635
8.  Mechanisms of Team-Sport-Related Brain Injuries in Children 5 to 19 Years Old: Opportunities for Prevention 
PLoS ONE  2013;8(3):e58868.
Background
There is a gap in knowledge about the mechanisms of sports-related brain injuries. The objective of this study was to determine the mechanisms of brain injuries among children and youth participating in team sports.
Methods
We conducted a retrospective case series of brain injuries suffered by children participating in team sports. The Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) database was searched for brain injury cases among 5–19 year-olds playing ice hockey, soccer, American football (football), basketball, baseball, or rugby between 1990 and 2009. Mechanisms of injury were classified as “struck by player,” “struck by object,” “struck by sport implement,” “struck surface,” and “other.” A descriptive analysis was performed.
Results
There were 12,799 brain injuries related to six team sports (16.2% of all brain injuries registered in CHIRPP). Males represented 81% of injuries and the mean age was 13.2 years. Ice hockey accounted for the greatest number of brain injuries (44.3%), followed by soccer (19.0%) and football (12.9%). In ice hockey, rugby, and basketball, striking another player was the most common injury mechanism. Football, basketball, and soccer also demonstrated high proportions of injuries due to contact with an object (e.g., post) among younger players. In baseball, a common mechanism in the 5–9 year-old group was being hit with a bat as a result of standing too close to the batter (26.1% males, 28.3% females).
Interpretation
Many sports-related brain injury mechanisms are preventable. The results suggest that further efforts aimed at universal rule changes, safer playing environments, and the education of coaches, players, and parents should be targeted in maximizing prevention of sport-related brain injury using a multifaceted approach.
doi:10.1371/journal.pone.0058868
PMCID: PMC3610710  PMID: 23555602
9.  UEFA Champions League study: a prospective study of injuries in professional football during the 2001–2002 season 
Background: No previous study on adult football involving several different countries has investigated the incidence and pattern of injuries at the highest club competitive level.
Objective: To investigate the risk exposure, risk of injury, and injury pattern of footballers involved in UEFA Champions League and international matches during a full football season.
Method: Eleven top clubs (266 players) in five European countries were followed prospectively throughout the season of 2001–2002. Time-lost injuries and individual exposure times were recorded during all club and national team training sessions and matches.
Results: A total of 658 injuries were recorded. The mean (SD) injury incidence was 9.4 (3.2) injuries per 1000 hours (30.5 (11.0) injuries per 1000 match hours and 5.8 (2.1) injuries per 1000 training hours). The risk of match injury was significantly higher in the English and Dutch teams than in the teams from France, Italy, and Spain (41.8 (3.3) v 24.0 (7.9) injuries per 1000 hours; p = 0.008). Major injuries (absence >4 weeks) constituted 15% of all injuries, and the risk of major injury was also significantly higher among the English and Dutch teams (p = 0.04). National team players had a higher match exposure, with a tendency towards a lower training injury incidence than the rest of the players (p = 0.051). Thigh strain was the most common injury (16%), with posterior strains being significantly more common than anterior ones (67 v 36; p<0.0001).
Conclusions: The risk of injury in European professional football is high. The most common injury is the thigh strain typically involving the hamstrings. The results suggest that regional differences may influence injury epidemiology and traumatology, but the factors involved are unclear. National team players have a higher match exposure, but no higher risk of injury than other top level players.
doi:10.1136/bjsm.2004.014571
PMCID: PMC1725291  PMID: 16046340
10.  A prospective epidemiological study of injuries in four English professional football clubs 
OBJECTIVE: To define the causes of injuries to players in English professional football during competition and training. METHOD: Lost time injuries to professional and youth players were prospectively recorded by physiotherapists at four English League clubs over the period 1994 to 1997. Data recorded included information related to the injury, date and place of occurrence, type of activity, and extrinsic Playing factors. RESULTS: In all, 67% of all injuries occurred during competition. The overall injury frequency rate (IFR) was 8.5 injuries/1000 hours, with the IFR during competitions (27.7) being significantly (p < 0.01) higher than that during training (3.5). The IFRs for youth players were found to increase over the second half of the season, whereas they decreased for professional players. There were no significant differences in IFRs for professional and youth players during training. There were significantly (p < 0.01) injuries in competition in the 15 minute periods at the end of each half. Strains (41%), sprains (20%), and contusions (20%) represented the major types of injury. The thigh (23%), the ankle (17%), knee (14%), and lower leg (13%) represented the major locations of injury, with significantly (p < 0.01) more injuries to the dominant body side. Reinjury counted for 22% of all injuries. Only 12% of all injuries were caused by a breach of the rules of football, although player to player contact was involved in 41% of all injuries. CONCLUSIONS: The overall level of injury to professional footballers has been showed to be around 1000 times higher times higher than for industrial occupations generally regarded as high risk. The high level of muscle strains, in particular, indicates possible weakness in fitness training programmes and use of warming up and cooling down procedures by clubs and the need for benchmarking players' levels of fitness and performance. Increasing levels of injury to youth players as a season progresses emphasizes the importance of controlling the exposure of young players to high levels of competition. 



PMCID: PMC1756169  PMID: 10378073
11.  The Relative Age Effect in Youth Soccer Players from Spain 
The purpose of this study was to identify the existence of Relative Age Effect (RAE) at youth level in both elite and amateur Spanish soccer clubs, and also to carry out an analysis providing with information on how this effect has evolved in recent years. We have obtained information on the youth teams of the 20 clubs belonging to the Spanish Professional Football League (LFP) in two separate seasons (2005-2006 and 2008-2009) as well as data on five youth academies belonging to amateur clubs. The collected data revealed an over- representation of players born in the first months of the selection year in all groups of analysis (Elite 2005-2006, Elite 2008-2009 and Amateurs), although only the Elite groups showed significant variations in birth-date distribution in relation to the Spanish population. The results showed a reduction in RAE from the 2005-2006 season to the 2008-2009 season. The following variables - playing position, the number of years each player has spent in their specific age group and the category of the team at each club were shown not to have influence on the extent of RAE.
Key pointsThere was RAE in all groups analyzed, although only the Elite groups showed significant variations in birth-date distribution in relation to the general population.RAE is more evident in the Elite groups than in the Amateur probably because of the detection process, which is more thorough in the Elite groups.Playing position, number of years in their specific age group and category of the team did not have any influence on the extent of RAE.Any attempts to prevent RAE should be based on a stable sport policy and the implication of all the stakeholders in the system. All of them should think in the development of a player as a long-term project.
PMCID: PMC3761747  PMID: 24149685
Relative age effect; season-of-birth bias; selection processes; talent identification; youth soccer
12.  Injury Incidence in a Spanish Sub-Elite Professional Football Team: A Prospective Study During Four Consecutive Seasons 
The aim of this study was to investigate the injury incidence and injury characteristics of a Spanish sub-elite professional football team during four consecutive seasons. A team was followed prospectively from the season 2003-2004 to 2006-2007 and individual player exposure and time loss injuries were recorded during all club training sessions and matches. A total of 313 time-loss injuries were recorded. The mean injury incidence was 10.9 injuries/1000 hours (5.2 injuries/1000 training hours and 44.1 injuries/1000 match hours). The injury incidence during competitive matches was higher (p < 0.001) than in friendly matches (55.8 vs. 22.6 injuries/1000 hours). The incidence of major injuries (>28 days absence) was 0.4 injuries/1000 hours. The thigh was the most commonly (35%) injured region and caused 29% of all competitive match absence. Muscle injuries in the four main groups of the lower limbs (hamstrings, adductors, quadriceps and calf muscles) caused 43% of competitive match unavailability. The results of this study show that the risk to sustain a major injury in the course of the season was low for sub- elite footballers in comparison to elite players. Thigh strains were the first cause of absence in competition due to injury.
Key pointsThe incidence of major injuries (absence greater than 4 weeks) was lower in a Spanish sub-elite football team than in elite European teams.The risk of sustaining an injury was 2.5 fold higher (p < 0.001) in official than in friendly matches.Lower limb muscular (hamstrings, quadriceps, hip adductors and calf muscles) and joint (knee and ankle) injuries were the main causes of match unavailability.
PMCID: PMC3761521  PMID: 24149566
Soccer; epidemiology; hamstrings; match play
13.  Recommendations of the National Football League Physician Society Task Force on the Use of Toradol® Ketorolac in the National Football League 
Sports Health  2012;4(5):377-383.
Ketorolac tromethamine (Toradol®) is a non-steroidal anti-inflammatory drug that has potent analgesic and anti-inflammatory properties. It can be administered orally, intravenously, intramuscularly, or via a nasal route. Ketorolac injections have been used for several years in the National Football League (NFL), in both the oral and injectable forms, to treat musculoskeletal injuries and to prevent post-game soreness. In an attempt to determine the appropriate use of this medication in NFL players, the NFL Team Physician Society appointed a Task Force to consider the best available evidence as to how ketorolac should be used for pain management in professional football players. These treatment recommendations were established based on the available medical literature taking into consideration the pharmacokinetic properties of ketorolac, its accepted indications and contraindications, and the unique clinical challenges of the NFL. The Task Force recommended that 1) ketorolac should only be administered under the direct supervision and order of a team physician; 2) ketorolac should not be used prophylactically as a means of reducing anticipated pain either during or after participation in NFL games or practices and should be limited to those players diagnosed with an injury or condition and listed on the teams’ injury report; 3) ketorolac should be given in the lowest effective therapeutic dose and should not be used in any form for more than 5 days; 4) ketorolac should be given in its oral preparation under typical circumstances; 5) ketorolac should not be taken concurrently with other NSAIDs or by those players with a history of allergic reaction to ketorolac, other NSAIDs or aspirin; and 6) ketorolac should not be used by a player with a history of significant gastrointestinal bleeding, renal compromise, or a past history of complications related to NSAIDs.
doi:10.1177/1941738112457154
PMCID: PMC3435943  PMID: 23016110
Toradol; Ketorolac; NFL; Football
14.  Preparticipation medical evaluation in professional sport in the UK: theory or practice? 
British Journal of Sports Medicine  2007;41(12):890-896.
Objective
To determine the level of pre‐employment, pre‐season, and post‐injury medical evaluation of players undertaken within UK professional team sports.
Design
A postal, whole population survey.
Setting
Elite professional sports teams in England.
Population
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).
Main outcome measures
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.
Results
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.
Conclusions
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.
doi:10.1136/bjsm.2007.038935
PMCID: PMC2658989  PMID: 17609223
preparticipation evaluation; professional sport; risk factors for injury; medical risk factors
15.  Evaluating Australian Football League Player Contributions Using Interactive Network Simulation 
This paper focuses on the contribution of Australian Football League (AFL) players to their team’s on-field network by simulating player interactions within a chosen team list and estimating the net effect on final score margin. A Visual Basic computer program was written, firstly, to isolate the effective interactions between players from a particular team in all 2011 season matches and, secondly, to generate a symmetric interaction matrix for each match. Negative binomial distributions were fitted to each player pairing in the Geelong Football Club for the 2011 season, enabling an interactive match simulation model given the 22 chosen players. Dynamic player ratings were calculated from the simulated network using eigenvector centrality, a method that recognises and rewards interactions with more prominent players in the team network. The centrality ratings were recorded after every network simulation and then applied in final score margin predictions so that each player’s match contribution-and, hence, an optimal team-could be estimated. The paper ultimately demonstrates that the presence of highly rated players, such as Geelong’s Jimmy Bartel, provides the most utility within a simulated team network. It is anticipated that these findings will facilitate optimal AFL team selection and player substitutions, which are key areas of interest to coaches. Network simulations are also attractive for use within betting markets, specifically to provide information on the likelihood of a chosen AFL team list “covering the line ”.
Key pointsA simulated interaction matrix for Australian Rules football players is proposedThe simulations were carried out by fitting unique negative binomial distributions to each player pairing in a sideEigenvector centrality was calculated for each player in a simulated matrix, then for the teamThe team centrality measure adequately predicted the team’s winning marginA player’s net effect on margin could hence be estimated by replacing him in the simulated side with another player
PMCID: PMC3761758  PMID: 24149734
Interaction matrix; negative binomial distribution; eigenvector centrality; player ratings
16.  Injuries in female football players in top‐level international tournaments 
British Journal of Sports Medicine  2007;41(Suppl 1):i3-i7.
Background
Despite the growing popularity of women's football and the increasing number of female players, there has been little research on injuries sustained by female football players.
Purpose
Analysis of the incidence, characteristics and circumstances of injury in elite female football players in top‐level international tournaments.
Study design
Prospective survey.
Methods
Injuries incurred in seven international football tournaments were analysed using an established injury report system. Doctors of all participating teams reported all injuries after each match on a standardised injury reporting form. The mean response rate was 95%.
Results
387 injuries were reported from 174 matches, equivalent to an incidence of 67.4 injuries/1000 player hours (95% CI 60.7 to 74.1) or 2.2 injuries/match (95% CI 2.0 to 2.4). Most injuries (84%; 317/378) were caused by contact with another player. The injuries most commonly involved the lower extremity (n = 248; 65%), followed by injuries of the head and neck (n = 67, 18%), trunk (n = 33, 9%) and upper extremity (n = 32, 8%). Contusions (n = 166; 45%) were the most frequent type of injury, followed by sprains or ligament rupture (n = 96; 26%) and strains or muscle fibre ruptures (n = 31; 8%). The most common diagnosis was an ankle sprain. There were 7 ligament ruptures and 15 sprains of the knee. On average 1 injury/match (95% CI 0.8 to 1.2) was expected to result in absence from a match or training.
Conclusion
The injury rate in women's top‐level tournaments was within the range reported previously for match injuries in elite male and female players. However, the diagnoses and mechanisms of injury among the female players differed substantially from those previously reported in male football players.
doi:10.1136/bjsm.2007.036020
PMCID: PMC2465250  PMID: 17646248
17.  The Preventing Australian Football Injuries with Exercise (PAFIX) Study: a group randomised controlled trial 
Injury Prevention  2009;15(3):e1.
Background:
Knee injuries are a major injury concern for Australian Football players and participants of many other sports worldwide. There is increasing evidence from laboratory and biomechanically focused studies about the likely benefit of targeted exercise programmes to prevent knee injuries. However, there have been few international studies that have evaluated the effectiveness of such programmes in the real-world context of community sport that have combined epidemiological, behavioural and biomechanical approaches.
Objective:
To implement a fully piloted and tested exercise training intervention to reduce the number of football-related knee injuries. In so doing, to evaluate the intervention’s effectiveness in the real-world context of community football and to determine if the underlying neural and biomechanical training adaptations are associated with decreased risk of injury.
Setting:
Adult players from community-level Australian Football clubs in two Australian states over the 2007–08 playing seasons.
Methods:
A group-clustered randomised controlled trial with teams of players randomly allocated to either a coach-delivered targeted exercise programme or usual behaviour (control). Epidemiological component: field-based injury surveillance and monitoring of training/game exposures. Behavioural component: evaluation of player and coach attitudes, knowledge, behaviours and compliance, both before and after the intervention is implemented. Biomechanical component: biomechanical, game mobility and neuromuscular parameters assessed to determine the fundamental effect of training on these factors and injury risk.
Outcome measures:
The rate and severity of injury in the intervention group compared with the control group. Changes, if any, in behavioural components. Process evaluation: coach delivery factors and likely sustainability.
doi:10.1136/ip.2008.021279
PMCID: PMC2684655  PMID: 19494090
18.  Non-participation in sports injury research: why football players choose not to be involved 
Methods: During the preseason, 10 Australian football clubs volunteered 23 teams to participate in a protective equipment randomised controlled trial, the Australian Football Injury Prevention Project (AFIPP). All players from these teams were invited to participate. Players who did not agree to participate in AFIPP were surveyed about their reasons for non-involvement.
Results: 110 football players (response rate 63.6%) completed the non-responder survey and cited the two main reasons behind non-involvement in the project as "I did not know about the project" (39.4%) and "I was not at training when the research team visited" (36.5%).
Conclusions and implications: Preseason may not be the best time for maximal player recruitment in community based sports safety research. Enhanced communication between researchers and players at community level football clubs during the recruitment phase is likely to improve response rates.
doi:10.1136/bjsm.2002.003525
PMCID: PMC1724785  PMID: 15039271
19.  Preventing knee injuries in adolescent female football players – design of a cluster randomized controlled trial [NCT00894595] 
Background
Knee injuries in football are common regardless of age, gender or playing level, but adolescent females seem to have the highest risk. The consequences after severe knee injury, for example anterior cruciate ligament (ACL) injury, are well-known, but less is known about knee injury prevention. We have designed a cluster randomized controlled trial (RCT) to evaluate the effect of a warm-up program aimed at preventing acute knee injury in adolescent female football.
Methods
In this cluster randomized trial 516 teams (309 clusters) in eight regional football districts in Sweden with female players aged 13–17 years were randomized into an intervention group (260 teams) or a control group (256 teams). The teams in the intervention group were instructed to do a structured warm-up program at two training sessions per week throughout the 2009 competitive season (April to October) and those in the control group were informed to train and play as usual. Sixty-eight sports physical therapists are assigned to the clubs to assist both groups in data collection and to examine the players' acute knee injuries during the study period. Three different forms are used in the trial: (1) baseline player data form collected at the start of the trial, (2) computer-based registration form collected every month, on which one of the coaches/team leaders documents individual player exposure, and (3) injury report form on which the study therapists report acute knee injuries resulting in time loss from training or match play. The primary outcome is the incidence of ACL injury and the secondary outcomes are the incidence of any acute knee injury (except contusion) and incidence of severe knee injury (defined as injury resulting in absence of more than 4 weeks). Outcome measures are assessed after the end of the 2009 season.
Discussion
Prevention of knee injury is beneficial for players, clubs, insurance companies, and society. If the warm-up program is proven to be effective in reducing the incidence of knee injury, it can have a major impact by reducing the future knee injury burden in female football as well as the negative long-term disabilities associated with knee injury.
Trial registration
NCT00894595
doi:10.1186/1471-2474-10-75
PMCID: PMC2711921  PMID: 19545453
20.  Community football players' attitudes towards protective equipment—a pre-season measure 
Background: The Australian football injury prevention project (AFIPP) was a randomised controlled trial examining the effects of protective equipment on injury rates in Australian Football.
Objective: To present the results of the AFIPP baseline survey of community football players' attitudes towards protective equipment.
Methods: Teams of players were recruited from the largest community football league in Victoria, Australia, during the 2001 playing season; 301 players were enrolled in the study and all were surveyed before the season began about their attitudes towards protective headgear and mouthguards.
Results: Almost three quarters of the players (73.6%) reported wearing mouthguards during the previous playing season (year 2000) compared with only 2.1% wearing headgear. The most common reasons for not wearing headgear and mouthguards (in non-users) were: "I don't like wearing it" (headgear: 44.8%; mouthguards: 30.6%), and "It is too uncomfortable" (headgear: 40.7%; mouthguards: 45.8%).
Conclusions: The higher mouthguard usage reflects the favourable attitudes towards mouthguards by Australian football players generally. Similarly, the low headgear usage reflects the low acceptance of this form of protection in this sport. Further research should be directed towards establishing the reasons why players seem to believe that headgear plays a role in injury prevention yet few wear it.
doi:10.1136/bjsm.2002.004051
PMCID: PMC1724861  PMID: 15273177
21.  Comparison of the incidence, nature and cause of injuries sustained on grass and new generation artificial turf by male and female football players. Part 2: training injuries 
British Journal of Sports Medicine  2007;41(Suppl 1):i27-i32.
Objective
To compare the incidence, nature, severity and cause of training injuries sustained on new generation artificial turf and grass by male and female footballers.
Methods
The National Collegiate Athletic Association Injury Surveillance System was used for a two‐season (August to December) prospective study involving American college and university football teams (2005 season: men 52 teams, women 64 teams; 2006 season: men 54 teams, women 72 teams). Injury definitions and recording procedures were compliant with the international consensus statement for epidemiological studies of injuries in football. Athletic trainers recorded details of the playing surface and the location, diagnosis, severity and cause of all training injuries. The number of days lost from training and match play was used to define the severity of an injury. Training exposures (player hours) were recorded on a team basis.
Results
The overall incidence of training injuries for men was 3.34 injuries/1000 player hours on artificial turf and 3.01 on grass (incidence ratio 1.11; p = 0.21) and for women it was 2.60 injuries/1000 player hours on artificial turf and 2.79 on grass (incidence ratio 0.93; p = 0.46). For men, the mean severity of injuries that were not season ending injuries was 9.4 days (median 5) on artificial turf and 7.8 days (median 4) on grass and, for women, 10.5 days (median 4) on artificial turf and 10.0 days (median 5) on grass. Joint (non‐bone)/ligament/cartilage and muscle/tendon injuries to the lower limbs were the most common general categories of injury on artificial turf and grass for both male and female players. Most training injuries were acute (men: artificial turf 2.92, grass 2.63, p = 0.24; women: artificial turf 1.94, grass 2.23, p = 0.21) and resulted from player‐to‐player contact (men: artificial turf 1.08, grass 0.85, p = 0.10; women: artificial turf 0.47, grass 0.56; p = 0.45).
Conclusions
There were no major differences between the incidence, severity, nature or cause of training injuries sustained on new generation artificial turf and on grass by either men or women.
doi:10.1136/bjsm.2007.037275
PMCID: PMC2465252  PMID: 17646247
acute; gradual onset; contact; non‐contact; risk
22.  Assessment of First-Aid Knowledge and Decision Making of High School Athletic Coaches 
Journal of Athletic Training  1999;34(3):267-271.
Objective:
To assess the first-aid knowledge and decision making of interscholastic athletic coaches exposed to athletic injuries.
Design and Setting:
Survey demographic information, First- Aid Assessment, and Game Situation Data Sheet in 17 metropolitan high schools.
Subjects:
A total of 17 metropolitan high schools participated in this study, and 104 athletic coaches completed questionnaires. Fifteen different athletic sports were represented in this investigation. Thirty coaches (29%) worked with more than one athletic sport during the year. Male subjects constituted 83% (n = 85) of the sample. Years of coaching experience ranged from first-year coaches to those with more than 28 years of experience. Most coaches (61%, n = 63) investigated were teachers, and the remaining subjects were walk-on coaches.
Measurements:
Central tendency scores were determined in the demographic analysis. x2 analyses were performed to determine the interaction between First-Aid Assessment and the Game Situation Data.
Results:
Thirty-eight (36%) of the 104 athletic coaches tested achieved passing scores of 29 or higher, with the total scores ranging from 19 to 34. For the Game Situation Data Sheet, 75% (n = 78) of the coaches selected the same response to 7 questions. Most coaches in this study chose to return injured players to the game. We analyzed the data to determine whether coaches who passed the First-Aid Assessment responded differently than those who did not. (The scenario presented in one question involved a starting player's sustaining injury when losing a close game.) Coaches who passed the First-Aid Assessment tended to return injured starters to the game, whereas those who failed it kept injured players out of the game. x2 analysis on the second question (the team is winning a close game when a regular player is injured) showed no tendency for passing or failing coaches to respond differently.
Conclusions:
The athletic coaches did not adequately meet first-aid standards as established for this study in accordance with the American Red Cross. In addition, coaches who passed the First-Aid Assessment tended to return an injured starter to the game, whereas those who failed decided to keep the player out of the game. It is critical that an unbiased, objective professional person provide all medical care on the athletic playing field, preferably one who is certified in athletic training.
PMCID: PMC1322921  PMID: 16558575
athletic injury; injury outcomes
23.  Comparison of the incidence, nature and cause of injuries sustained on grass and new generation artificial turf by male and female football players. Part 1: match injuries 
British Journal of Sports Medicine  2007;41(Suppl 1):i20-i26.
Objective
To compare the incidence, nature, severity and cause of match injuries sustained on grass and new generation artificial turf by male and female footballers.
Methods
The National Collegiate Athletic Association Injury Surveillance System was used for a two‐season (August to December) prospective study of American college and university football teams (2005 season: men 52 teams, women 64 teams; 2006 season: men 54 teams, women 72 teams). Injury definitions and recording procedures were compliant with the international consensus statement for epidemiological studies of injuries in football. Athletic trainers recorded details of the playing surface and the location, diagnosis, severity and cause of all match injuries. The number of days lost from training and match play was used to define the severity of an injury. Match exposures (player hours) were recorded on a team basis.
Results
The overall incidence of match injuries for men was 25.43 injuries/1000 player hours on artificial turf and 23.92 on grass (incidence ratio 1.06; p = 0.46) and for women was 19.15 injuries/1000 player hours on artificial turf and 21.79 on grass (incidence ratio = 0.88; p = 0.16). For men, the mean severity of non‐season ending injuries was 7.1 days (median 5) on artificial turf and 8.4 days (median 5) on grass and, for women, 11.2 days (median 5) on artificial turf and 8.9 days (median 5) on grass. Joint (non‐bone)/ligament/cartilage and contusion injuries to the lower limbs were the most common general categories of match injury on artificial turf and grass for both male and female players. Most injuries were acute (men: artificial turf 24.60, grass 22.91; p = 0.40; women: artificial turf 18.29, grass 20.64; p = 0.21) and resulted from player‐to‐player contact (men: artificial turf 14.73, grass 13.34; p = 0.37; women: artificial turf 10.72; grass 11.68; p = 0.50).
Conclusions
There were no major differences in the incidence, severity, nature or cause of match injuries sustained on new generation artificial turf and grass by either male or female players.
doi:10.1136/bjsm.2007.037267
PMCID: PMC2465254  PMID: 17646246
acute; gradual onset; contact; non‐contact; risk
24.  The Football Association medical research programme: an audit of injuries in academy youth football 
Objectives: To undertake a prospective epidemiological study of the injuries sustained in English youth academy football over two competitive seasons.
Methods: Player injuries were annotated by medical staff at 38 English football club youth academies. A specific injury audit questionnaire was used together with a weekly return form that documented each club's current injury status.
Results: A total of 3805 injuries were reported over two complete seasons (June to May) with an average injury rate of 0.40 per player per season. The mean (SD) number of days absent for each injury was 21.9 (33.63), with an average of 2.31 (3.66) games missed per injury. The total amount of time absent through injury equated to about 6% of the player's development time. Players in the higher age groups (17–19 years) were more likely to receive an injury than those in the younger age groups (9–16 years). Injury incidence varied throughout the season, with training injuries peaking in January (p<0.05) and competition injuries peaking in October (p<0.05). Competition injuries accounted for 50.4% of the total, with 36% of these occurring in the last third of each half. Strains (31%) and sprains (20%) were the main injury types, predominantly affecting the lower limb, with a similar proportion of injuries affecting the thigh (19%), ankle (19%), and knee (18%). Growth related conditions, including Sever's disease and Osgood-Schlatter's disease, accounted for 5% of total injuries, peaking in the under 13 age group for Osgood-Schlatter's disease and the under 11 age group for Sever's disease. The rate of re-injury of exactly the same anatomical structure was 3%.
Conclusions: Footballers are at high risk of injury and there is a need to investigate ways of reducing this risk. Injury incidence at academy level is approximately half that of the professional game. Academy players probably have much less exposure to injury than their full time counterparts. Areas that warrant further attention include the link between musculoskeletal development and the onset of youth related conditions such as Sever's disease and Osgood-Schlatter's disease, the significant number of non-contact injuries that occur in academy football, and the increased rates of injury during preseason training and after the mid season break. This study has highlighted the nature and severity of injuries that occur at academy level, and the third part of the audit process now needs to be undertaken: the implementation of strategies to reduce the number of injuries encountered at this level.
doi:10.1136/bjsm.2003.005165
PMCID: PMC1724880  PMID: 15273188
25.  Should football players wear custom fitted mouthguards? Results from a group randomised controlled trial 
Injury Prevention  2005;11(4):242-246.
Objective: Head/orofacial (H/O) injuries are common in Australian rules football. Mouthguards are widely promoted to prevent these injuries, in spite of the lack of formal evidence for their effectiveness.
Design: The Australian football injury prevention project was a cluster randomized controlled trial to evaluate the effectiveness of mouthguards for preventing H/O injuries in these players.
Setting and subjects: Twenty three teams (301 players) were recruited from the largest community football league in Australia.
Intervention: Teams were randomly allocated to either the MG: custom made mouthguard or C: control (usual mouthguard behaviours) study arm.
Main outcome measures: All injuries, participation in training and games, and mouthguard use were monitored over the 2001 playing season. Injury rates were calculated as the number of injuries per 1000 person hours of playing time. Adjusted incidence rate ratios were obtained from Poisson regression models.
Results: Players in both study arms wore mouthguards, though it is unlikely that many controls wore custom made ones. Wearing rates were higher during games than training. The overall rate of H/O injury was 2.7 injuries per 1000 exposure hours. The rate of H/O injury was higher during games than training. The adjusted H/O injury incidence rate ratio was 0.56 (95% CI 0.32 to 0.97) for MG versus C during games and training, combined.
Conclusions: There was a significant protective effect of custom made mouthguards, relative to usual mouthguard use, during games. However, the control players still wore mouthguards throughout the majority of games and this could have diluted the effect.
doi:10.1136/ip.2004.006882
PMCID: PMC1730251  PMID: 16081755

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