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The abrasion accident in able football is high. A analysis accumulation in the English Football Association (FA) evaluated the abrasion arrangement and accident of abrasion in a alternation of studies of able football in England.1,2 They showed that the all-embracing accident was about 1000 times college for able players than for aerial accident automated occupations.



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The administering bodies for all-embracing football, FIFA (Federation of All-embracing Football Associations) and UEFA (Union of European Football Associations), as able-bodied as civic football associations accept bidding their affair about the demands placed on the avant-garde footballer, and the adaptation of these concrete and brainy demands into injuries.3

Different analysis groups accept accomplished projects to abstraction the accident and causes of abrasion in football—for example, the FA group,1,2,4–7 the FIFA Medical Appraisal and Analysis Center (F-MARC),8,9,10 and the Oslo Sports Agony Analysis Center.11–15 Their ultimate ambition is to anticipate injuries and thereby advance the assurance of the sport. Preventive measures are based on epidemiological research, and the aboriginal footfall in abrasion blockage is to authorize the admeasurement of the abrasion problem—the incidence, severity, and abrasion contour of the sport.16



One botheration associated with epidemiological appraisal of football injuries is the inconsistent address in which abrasion is authentic and abstracts are calm and recorded. No accord exists about abstraction design, abstracts collection, abrasion definition, and ascertainment period.16–19 To adapt the after-effects of an epidemiological abstraction on football injuries, it is all-important to analyze the after-effects with abstracts from added appear studies. However, the abstruse differences amid studies may be greater than any statistically cogent aberration in the results. Meaningful comparisons of abrasion ante and abrasion patterns can alone be fabricated amid studies application agnate abstraction designs, definitions, and abstracts accumulating methods.3

In 1999, UEFA accomplished a analysis action that aims to abatement the cardinal of injuries and admission anatomic assurance for able footballers. To activate with, the UEFA Medical Board discussed the abstruse architecture and arrangement for abrasion reporting. Several sports abrasion advertisement systems accept been developed,20–23 but no arrangement has been analogously accepted. Sports abrasion surveillance systems should be action specific.23 The aim of the discussions of the UEFA Medical Board was to advance the optimum adjustment for anecdotic epidemiological studies on football at the able level, and to advance a football specific abrasion advertisement system.



The purpose of this analysis is to call the development of the UEFA archetypal and to accommodate applied guidelines for approaching studies based on absolute sports abrasion surveillance systems and our acquaintance application the UEFA model.

The development and validation of the abstraction architecture and abrasion advertisement arrangement was agitated out in three stages:

In 1999 and 2000, discussions were captivated aural the UEFA Medical Board about optimal abstraction architecture and advertisement methodology. Parts of these discussions accept been appear previously.3 The Medical Board was able to ability an actual accord on some abstruse aspects at the antecedent meetings: the abstraction design, acknowledgment registration, abstraction period, and abstracts accumulating forms. In added areas, an actual accord could not be reached, and a check was developed and acclimated as a base for added accord discussions. A majority accommodation was acclimated for questions for which accord could not be reached.

In January 2001, two pilot studies on the able leagues in Sweden (full season) and Denmark (spring season) were started to analysis abstraction architecture and abstracts collection. Abounding letters of the after-effects from these studies are presented elsewhere.24,25

Before the alpha of the UEFA Champions Alliance (UCL) abstraction in July 2001, aggregation doctors from the arrive teams alternate in a affair in Nyon, Switzerland (UEFA headquarters), in May 2001. Here, the proposed abstruse design, definitions, and advertisement forms were discussed in detail based on acquaintance from the aboriginal pilot studies, and these were accustomed afterwards accessory revision.

Studies should accept a -to-be accomplice design. This is because the attendant architecture is associated with a able-bodied accepted accident of anamnesis bias, as afresh apparent by the F-MARC group.9 Furthermore, a -to-be accomplice abstraction is a added able abstraction architecture than a case-control abstraction aback the purpose is to actuate the accident factors for injury.26 Finally, with a -to-be design, it is accessible to admeasurement accurately acknowledgment to accident of injury.

To appraise the abrasion accident in a assertive sport, the acknowledgment agency needs to be considered—that is, the time during which the actor is at accident of abrasion should be measured.27 On the base of an authentic acknowledgment record, abrasion accident can be expressed, usually as the cardinal of injuries per 1000 hours of participation.16 Ideally, the acknowledgment almanac should be alone and based on absolute acknowledgment time, rather than on an appraisal based on appearance during training sessions and matches. If alone acknowledgment is recorded, a added avant-garde archetypal can be acclimated to abstraction accident factors for injury: a Cox proportional hazards corruption model. Acknowledgment time, abstinent as the cardinal of hours of acknowledgment for anniversary abecedarian (training and bout participation), from the alpha of the chase up aeon (the alpha of the season) until the accident (the aboriginal injury) or the end of chase up (for players who are not injured) is the capital capricious here. The backbone of this admission is that the adjustment can be adapted for the actuality that arena time can alter abundantly amid players in a team. This may be important, because the best players comedy added abecedarian than the substitutes, and conceivably alike alternation harder. It additionally takes censorship into account—that is, beneath chase up for affidavit added than injury, such as sickness, affective to a altered club, abandonment the action for affidavit added than injury.

Injury accident and arrangement alter over the football season,5,28–30 which is why the abstraction aeon should accommodate the absolute season, or several seasons, including both the preseason and the aggressive season.

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Basically, three altered forms are adapted for the accumulating of abstracts in a abstraction of abrasion accident in sports.23

Firstly, a baseline anatomy on which at atomic anthropometric abstracts and antecedent medical history are noted. The baseline anatomy developed for the UEFA studies includes advice about abecedarian age, weight, height, ascendant leg (kicking leg), and history of antecedent aloft injuries and operations. The anatomy is additionally acclimated to admission abreast consent. Depending on the purpose of the study, the anatomy can be broadcast to accommodate added variables from the preseason appraisal of abeyant accident factors—for example, training background, arena experience, goniometric measurements, collective abandon measurements, the after-effects of fettle tests, abecedarian positions. As a medical history based on advice from the abecedarian may be ashamed by anamnesis bias, it is recommended that players are provided with a archetype of their club medical annal afore actuality transferred to accession club. It may alike be accessible to advance accepted forms for this purpose.

Secondly, a anatomy is adapted on which appearance and alone acknowledgment is recorded. This can be a account or account anatomy of attendance, and it should awning all training sessions and matches for the players included. The basal appearance almanac developed for the UEFA studies includes a account of players’ names and cipher numbers, and a cavalcade for anniversary training affair and bout in which alone accord is recorded in minutes. The appearance almanac can additionally be adapted to clothing the purposes of the study—for example, the accession of acclimate conditions, arena apparent (grass against bogus turf), or advice on training agreeable (strength training, brawl training, etc).

Thirdly, advice about injuries should be recorded on a accepted abrasion address form. This should at atomic accommodate advice about the date of injury, whether the abrasion occurred during training or bout play, the abrasion type, location, and a admeasurement of abrasion severity. As the antecedent analysis may afterwards be revised afterwards radiographic analysis or added consultation, it should be fatigued to those accession abstracts that this new advice charge be added to the abrasion form. For the UEFA studies, it was absitively that the abrasion anatomy should be belted to one folio and alone a few questions. Advice about the blazon and affairs of abrasion are recorded in collapsed form. Depending on the purpose of the study, specific advice can be added to the abrasion form—for example, acquaintance or non-contact injury, abrasion mechanisms, arena surface, acclimate conditions. As a rule, to accredit appraisal of the aftereffect of a agency on abrasion risk, abstracts accompanying to this agency charge to be recorded on the abrasion anatomy and on the acknowledgment form.

Individual accounting abreast accord should be acquired from all accommodating players in accordance with the Declaration of Helsinki, and studies should be evidently advised by an adapted belief committee.

A affair with epidemiological studies in which abounding assemblage are complex is to ensure that abstracts are calm in a constant fashion. An apprenticeship chiral was accordingly created for the UEFA studies, and broadcast to the clubs afore the alpha of the study. Such a chiral should call the assorted definitions acclimated in the abstraction in detail. It should additionally accord examples of how to ample in the assorted forms and, especially, accommodate absurd cases that represent altered scenarios area it ability be difficult to apperceive how to complete the forms.

Each club should baddest a acquaintance actuality amenable for commutual and sending in the abstraction forms to the analysis staff. To be able to accurately almanac alone acknowledgment in the UEFA studies, a archetype for bushing in the appearance almanac (exposure form) was that the actuality amenable should be accessible at all training sessions and matches. It was absitively that alluringly a affiliate of the medical aggregation (team doctor or physiotherapist) should be amenable for bushing in the forms and advanced them to the analysis staff. However, in clubs area the medical aggregation does not appear all convenance sessions or matches, altered solutions should be sought—for example, an abettor drillmaster or accessories manager. It should be acutely declared who was the prime eyewitness in a abstraction as differences in abstracts accumulating methods may baffle with comparisons amid studies.

Previous studies conducted at abecedarian and semiprofessional levels accept included a anchored cardinal of players in anniversary team—for example, the “top” 15 or 18 players in the team.12,31,32 However, at the able level, the cardinal of apprenticed players is higher. It was argued that the exclusion of a cardinal of players in a aggregation ability acquaint alternative bias. Accordingly it was absitively that all players with a aboriginal aggregation arrangement should be included. This admission has additionally been acclimated in added contempo studies.11

In some studies, players with an absolute abrasion or a history of a austere injury—for example, automated alternation of the knee joint—have been excluded.33 This would acquaint a abeyant bias, both accompanying to the all-embracing appraisal of abrasion accident and to any estimations of accident agency performed. It was accordingly absitively that players with a antecedent abrasion should not be excluded. Players with an absolute abrasion at the alpha of the abstraction should additionally be included, but that authentic abrasion would not be included in the abrasion statistics, and the acknowledgment not included until the abecedarian is absolutely austere for all activities.

To acquiesce allegory amid altered studies, injuries accept to be authentic in a agnate way.3,16,18 Best studies of football injuries accept acclimated a “time loss” analogue of injury, acceptation that a recordable abrasion is one that causes absence from football participation.1,2,12,13,28,29,31,32,34–39 Added definitions of abrasion crave that the abecedarian needs medical analysis for the abrasion (“medical assistance” definition),40–42 or that an abrasion is recorded behindhand of whether or not it causes consecutive absence from training or bout comedy (“tissue injury” definition).10,20 Some studies accept acclimated a aggregate of the aloft definitions.43–46

Some authors accept recommended the use of the tissue abrasion definition,9,19 partly because of the abstract apparatus of the time accident definition. A tissue abrasion analysis may be the best cold adjustment to actuate whether an abrasion has occurred. However, a absolutely cold tissue abrasion analogue is hardly acclimated because specific cold criteria—for example, assay with alluring resonance imaging, ultrasound, etc—have to be included and these are usually cher and not consistently practical. If cold examinations are not agitated out, an eyewitness and accommodating bent is introduced. The eyewitness is abstract in his/her acumen of a tissue injury, and the abecedarian is abstract in his acknowledgment to the examination.

A medical absorption analogue was not believed to be the best acceptable as this would accommodate abounding accessory injuries and incidents that are not cogent for the all-embracing abrasion risk. Moreover, application a medical absorption analogue could acquaint a bent amid teams area medical absorption is calmly available, such as in the aloft European football leagues, and teams that accept no aggregation doctor and area the physiotherapist alone attends some training sessions and not alike all matches.12 It is acceptable that the advertisement beginning would be essentially college in the closing case, arch to an allegedly lower abrasion incidence.

For the UEFA studies, it was absitively that the time accident analogue of abrasion was acceptable for studies at the able level. Although this analogue depends on the abundance of training sessions and matches, the teams at the able akin usually alternation or attempt daily, which minimises the accident of missing beneath astringent injuries. Furthermore, it can be argued that injuries consistent in time absent from training and matches accept a abundant appulse on the player’s bloom and performance,17 and additionally on the achievement of the club, and accordingly should be recorded.

In the pilot abstraction on the Swedish able league, we compared a time accident abrasion definition, as authentic by Ekstrand,47 with a tissue abrasion definition, as authentic by Junge and Dvorak,9 and begin no aberration in abrasion accident aback application these definitions.25 Thus, at aristocratic levels the aberration amid a time accident and a tissue abrasion analogue may be minimal. However, it should be acclaimed that at lower levels, teams accept beneath training sessions and matches, and this increases the accident of missing beneath astringent injuries with alone one or two canicule absence. On the added hand, as admission to medical ability is usually additionally bound at lower levels, the recording of injuries accurately based on a tissue abrasion analogue could additionally be hampered.

The analogue of a time accident abrasion varies in the literature. Altered letters accept authentic abrasion as: causing absence from the abutting training affair or bout afterwards the event,29,31,32,36–38 actuality clumsy to participate in a bout or training affair because of an injury,12,35 causing absence from training and matches for at atomic one day,1,13 two days2,28 or one anniversary afterwards an incident.39 Clearly, an acceding on a compatible time accident abrasion analogue is needed. The abrasion analogue agreed on by the UEFA Medical Board was a time accident analogue ahead acclimated by Ekstrand47: an abrasion that occurred during a appointed training affair or bout that acquired absence from the abutting training affair or match. It may additionally be adapted to accommodate injuries that account the abecedarian to arrest a training affair or match, behindhand of whether the abecedarian misses the abutting training affair or match. This is abnormally important at lower levels, area training and matches are beneath frequent. These injuries could again be appear in a abstracted class as “zero day” time accident injuries.

Care should additionally be taken to analyze amid the recording analogue and the advertisement definition. Alike in a abstraction area injuries are recorded application a medical absorption or tissue abrasion definition, in the final address it is analytical that, as a minimum, the cardinal of injuries that account time loss, as able-bodied as the agnate time accident abrasion accident are appear separately, not alone the accident of medical absorption injuries or injuries causing tissue damage. This would again acquiesce consecutive allegory amid this abstraction and others application a time accident definition.

When application a time accident abrasion analogue it is important to booty abrasion severity into consideration,16 and this is usually declared according to the cardinal of canicule of absence from participation.1,2,12,29,30,34,37,39,48 The absolute point for altered categories of abrasion severity differs amid studies.9 According to the UEFA accord discussions, abrasion severity was initially categorised as accessory (1–7 canicule absence), abstinent (8–28 days), and aloft (>28 days). The aboriginal accumulation was afterwards breach into two categories (slight (1–3 canicule absence) and accessory (4–7 days)) to facilitate comparisons with the studies of the FA group.1,2 The severity should be based on absolute time accident from accord (calculated from the appearance record) and not from an estimated absence period.

A prerequisite for allegory of abrasion patterns amid studies is that altered types of injuries are acutely acclaimed and authentic in a agnate way by altered researchers, as able-bodied as altered observers. Commonly, authors analyze amid injuries that aftereffect from overuse and those that aftereffect from agony (acute injuries), although definitions alter greatly.9 In the UEFA studies, abrasion types were disconnected into seven altered categories (table 1). A agnate admission has been acclimated in added studies.11,18,38

 Classification of altered abrasion types

Only injuries occurring during appointed aggregation activities should be included in the statistics. Injuries that action during leisure time or from accommodating in added sports (outside aggregation training) and absence as a aftereffect thereof should not be counted, as the purpose is to appraise the accident of abrasion for able footballers and not the all-embracing accident of abrasion including added activities. However, aggregation activities are not usually bound to football training and matches, but additionally accommodate assorted forms of fettle training (strength building, running, etc). To call the authentic accident of abrasion to a able footballer, the injuries and acknowledgment to activities added than football should additionally be recorded. However, these should be appear alone from football training and matches.

A reinjury is usually authentic as an abrasion occurring afterwards an antecedent abrasion of the aforementioned blazon and location. We debated whether a specific time aeon should be included in the definition—for instance, an identical abrasion aural the aforementioned season—or whether no time absolute should be adopted. The accommodation was that a reinjury should be authentic as an abrasion of the aforementioned blazon and area of a antecedent abrasion that occurred aural two months of the final rehabilitation day of the antecedent injury.

It could be argued that injuries may account deficits in proprioception and structural damage, such as blister tissue in muscles, that may still be present added than two months afterwards the antecedent injury. This abstraction is authentic by studies that accept apparent that antecedent abrasion is a able accident agency for a new identical abrasion during a season.12 Added injuries never alleviate absolutely and may backpack an added accident of reinjury behindhand of time, such as a reconstructed antecedent cruciate bond injury, or afterwards a fractional meniscectomy. However, a time absolute of two months was called to abstain anamnesis bent for injuries that had occurred afore the alpha of the study. It was argued that anamnesis bent ability baffle aback application a reinjury analogue such as accepting anytime had a antecedent abrasion during a career or during a above-mentioned season. At the able level, best teams accumulate authentic medical records, and it ability be accessible to accurately trace injuries several seasons back. However, these annal may not be as absolute for players transferred from lower akin teams.

Even a time accident analogue such as that acclimated by UEFA leaves some allowance for interpretation. The catechism is aback should a abecedarian be classified as accepting alternate to activity, as this determines the abrasion severity and reinjury rate. Is this aback he begins demography allotment in organised training, conceivably abating up with the team, but is not yet accessible to booty allotment in all aggregation activities? In principle, acknowledgment to action should betoken that the abecedarian is advised absolutely active afterwards an injury.

According to the UEFA model, it was absitively that a abecedarian should be able to booty allotment in 100% of the team’s training programme to be recorded as accommodating in that session. If a abecedarian participates in a allotment of the training affair only, again this abecedarian should be admired as injured. Árnason et al35 accept appropriate that the abecedarian is authentic as afflicted until he is able to comedy a bout or accede absolutely with all instructions accustomed by the coach, including sprinting, turning, shooting, and arena football at abounding tempo. At the able level, the aggregation medical agents commonly decides aback the abecedarian is able to acknowledgment to football. Thus, a abecedarian is advised afflicted until he is accustomed approval by the medical agents to participate absolutely in aggregation training and bout play.28 Likewise, if a abecedarian participates in a adapted training programme to abstain aggravating an basic affliction syndrome, this abecedarian should additionally be recorded as injured.

The accommodation as to aback a abecedarian is advised absolutely active is still subjective, and accepted acknowledgment to comedy belief would facilitate allegory amid studies or amid altered subgroups (different teams, bounded locations, etc) aural the abstraction population. A acceptable archetype could be that players should ability assorted preseason concrete ambit or anatomic account ethics afore actuality accustomed aback to play. To date, no such tests accept been appropriately evaluated.

A abecedarian who sustains an end of division abrasion should finer be followed until the final rehabilitation date. If this is not possible—for example, the abecedarian is transferred to accession club—the aggregation medical agents should accommodate an estimated date of acknowledgment to abounding aggregation training and bout comedy on the abrasion card.

As mentioned above, players may leave the club during the season—for example, they may be transferred to accession club or leave because of illness. These players should be censored aback abrogation the club, but their acknowledgment and abrasion abstracts should be included until the day they leave the team. If a abecedarian is afflicted aback he leaves the club, the consecutive absence should be followed up for advice of the date of acknowledgment to abounding football activity.

A training affair was authentic as: a drillmaster directed concrete action agitated out with the team. A accretion affair with basin training afterwards a bout and a backbone affair in the gym should appropriately be recorded as training sessions, admitting a abstract session—for example, video, aggregation meeting—should not be recorded. Alone training sessions should not be included in the analogue of a recordable training affair because these are adamantine to standardise and it would be difficult to annals alone sessions accurately.

No abstruse accord exists for epidemiological studies of sports injuries.

Owing to variations in abstraction design, analogue of injury, and abstracts accumulating methods, it is difficult to analyze the after-effects amid studies.

At the able level, abounding teams accept players who participate in civic aggregation activities and matches. It was absitively that acknowledgment and injuries that resulted from civic aggregation accord should be recorded for the players involved. The accident of overexertion is a aloft affair at the accomplished able level,49 and it is capital to accommodate civic aggregation appearances to be able to abstraction the training and bout amount in affiliation to abrasion accident of the alone abecedarian in anniversary team.

One botheration is to ensure that authentic acknowledgment and abrasion advice is actuality calm during accord in civic aggregation play. Abrasion surveillance systems accept been auspiciously implemented at the civic aggregation akin in FIFA tournaments,20,41 and agnate assignment is actuality agitated out by UEFA during European tournaments. However, there are alone a few letters that accommodate abstracts on appearances alfresco aloft tournaments.14,36,50 Accepted recording of acknowledgment and abrasion abstracts during all civic aggregation gatherings, including affable appearances and training camps, is all-important to present an authentic account of abrasion accident and arrangement at the accomplished able level.

Likewise, it was absitively that acknowledgment and injuries for aboriginal aggregation players who participate with assets teams or adolescence teams should additionally be recorded. However, if a aboriginal aggregation abecedarian participates in a training affair or bout with the assets aggregation as a allotment of rehabilitation afterwards an injury, this should not be recorded as training or bout attendance. Instead, he should be recorded as afflicted until he has been accustomed approval from the medical agents to participate absolutely in aggregation training and bout comedy with the aboriginal team, as declared above.

Common pitfalls encountered in epidemiological studies on football injuries are discussed.

Practical guidelines and a abstruse account that may serve as the accepted for studies on footballers at the able akin are provided.

Table 2 shows a appropriate account for epidemiological studies of football injuries.

 Checklist for epidemiological studies of football injuries: the UEFA model

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