Lawrence Mayhew

Football has several associated health-related benefits, although the change in physical demands of the game, alongside increased training exposure, physical contact and tackles, places women players at a high risk of injury. In this chapter, an insight into the incidence and prevalence of injury in women’s football is provided. The sites, tissues and types of injuries sustained are characterised based on previous research. The growing need for illness and wellness monitoring, reporting and recording menstrual history, menstrual cycle and use of hormonal contraceptives related to the aetiology of injury and illness are highlighted. In a small but central part of the chapter, the importance that the medical team (“the team behind the team”) plays in supporting the health and wellness of players is discussed, and, therefore, recommendations for recording and reporting match and training exposure are presented. This chapter also includes information on incidents that may pose a threat to life. Current global guidance, along with recent published literature, provides the reader with knowledge that can be applied pitch side for immediate trauma care in women’s football. Underpinned by up-to-date literature, this guidance and practice will be readily transferable to those working in the women’s game.

The epidemiology of injury in male professional football is well documented and has been used as a basis to monitor injury trends and implement injury prevention strategies over decades. There are no systematic reviews that have investigated injury incidence in women’s professional football. Therefore, the extent of injury burden in women’s professional football is currently unknown. PURPOSE: The primary aim of this study was to calculate an overall incidence rate of injury in senior female professional soccer. The secondary aims were to provide an incidence rate of injury statistic for training and match play. METHODS: PubMed, Discover, Academic Search Complete (EBSCO), Embase, SPORTDiscus and ScienceDirect electronic databases were searched from inception to September 2018. Two reviewers independently assessed study quality using the Strengthening the Reporting of Observational Studies in Epidemiology statement using a 22-item STROBE checklist. 7 prospective studies were combined in a pooled analysis of injury incidence using a mixed effects model. Heterogeneity was evaluated using the Cochrane Q statistic and I2. RESULTS: The mean total incidence of injury in Senior professional Female Soccer players was found to be 3.15 (95% CI 1.54 – 4.75) injuries per 1000 hours. In a sub group analysis, the mean incidence of injury during match play was 10.72 (95% CI 9.11 – 12.33) and during training was 2.21 (95% CI 0.96 – 3.45). Data analysis found a significant level of heterogeneity (total Incidence, X2 = 16.57 P < 0.05; I2 = 63.8%) and during subsequent sub group analyses in those studies reviewed (match incidence, X2 = 76.4 (d.f. = 7), P <0.05; I2 = 90.8%, training incidence, X2 = 16.97 (d.f. = 7), P < 0.05; I2 = 58.8%). An appraisal of the study methodologies revealed inconsistency in the use of injury terminology, data collection procedures, calculation of exposure and operational measures of performance by researchers. Such inconsistencies likely contribute to the large variance in the incidence and prevalence of injury reported. CONCLUSIONS: Continued reporting of heterogeneous results in population samples limits meaningful comparison of studies. Standardising the criteria used to attribute injury and activity coupled with more accurate methods of calculating exposure will overcome such limitations

Background Despite the professionalization of women’s football the incidence and prevalence of injuries occurring within England is currently unknown. Objective To estimate the incidence, prevalence and nature of injury in a single professional Women’s football squad over one season (2018/2019) Design Prospective single site cohort study. Setting Professional women’s football squad competing in the English Women’s Championship. Patients (or Participants) 25 players with a professional contract. Ethical approval was obtained from Leeds Beckett University. Interventions (or Assessment of Risk Factors) Data collection procedures followed the UEFA consensus guidelines. Player exposures were recorded via GPS for all football related activity Main Outcome Measurements Incidence of injury per 1000h of exposure, prevalence and severity of injury per anatomical site, epidemiologic incidence proportion and clinical incidence to provide measures of injury burden and resource management. Results The incidence of injury was 8.04/1000 h (95% CI 4.32–11.77), 30.68/1000 h (95% CI 14.61–47.75) during match play and 2.24/1000 h (95% CI: 0.25–4.66) during training. A total of 18 injuries including re-injuries were sustained providing a clinical incidence of 0.72 (95% CI 0.54–0.89) injuries per player. The most common sites of injury were the knee (5/18, 27%) and anterior thigh (3/18, 17%). There was 1 non time loss injury, 3 minimal injuries (16.6%; 1–3 days), 4 mild (22.2%; 4- 7 days), 6 moderate (33,3%; 8 – 28 days) and 4 severe injuries (22.2%; > 28 days). Of the 5 knee injuries, 2 were ruptures of the anterior cruciate ligament via a non-contact mechanism. Epidemiological incidence proportion was 0.44 (95% CI: 0.24–0.74) thus the average probability that any player would sustain at least one injury was 44% (95% CI: 25%-63%). Conclusions This is the first prospective investigation capturing injury incidence from a cohort of English players. The relatively high proportion of ACL injuries imposes a significant burden on a squad of this size. Multi-site prospective investigations of injury are required

Background: In a recent single season audit of men’s English professional football, the incidence of injury was reported as 9.11 injuries/1000 h (Jones et al., 2019). Whilst this provides an up to date estimate of a single season, there is a paucity of research examining the incidence of injury over multiple seasons in English football. Objective: The aim of this study was to examine the injury trends in English professional football over 11 seasons (2007/8–2013/14 and 2015/16–2018/19). Design: Retrospective case series. Setting: Professional football players competing in the English Football League. Participants: 363 players from four squads. Main outcome: Data collection procedures followed the guidelines set out in the Union of European Football Associations (UEFA) consensus for all 11 seasons. Injury incidence per 1000 h was estimated from match and training exposure. Results: There were 907 injuries recorded over 11 years. The overall incidence rate was 6.5/1000 h (95% CI). The incidence rate in match play was significantly higher than training (58 vs 2.8/1000 h, P<0.001, 95% CI). Incidence rates remained stable over 11 years and there was no significant difference for muscle and ligament incidence rates between seasons (<0.05). The most common site of injury was the thigh, (27%, 242/907). Muscle strains accounted for 49% (445/907) of all injuries. The hamstrings were the most frequently injured muscle group, accounting for 17% (150/907) of all injuries and 34% (150/445) of muscle injuries. There was a significant increase in the number of hamstring injuries occurring during match play across seasons (P=0.024, 95% CI). Re-injuries constituted 6% (55/907) of all injuries and caused longer absences than initial injury (14.7 vs 8.5, P<0.001, 95% CI). Conclusions: Whilst overall incidence rates remain stable, the incidence of hamstring injuries remains high and re-injuries had a higher severity than initial injuries.

Background There is a paucity of longitudinal epidemiological injury data in football players competing in the English Football League (EFL). The aim of this study was to report the incidence, site and nature of injury in professional male football players over 11 seasons. Study Design Retrospective case series. Methods Three-hundred and sixty-three professional football players from four squads competing in the EFL. Data collection procedures followed the guidelines set out in the Union of European Football Associations (UEFA) consensus for all 11 seasons. Injury incidence per 1000 hours was estimated from match and training exposure. Results Overall injury incidence was 6.5/1000 hours (95% CI 5.6-7.5). Incidence of injury in match play was significantly higher than training (58/1000 hours, 95% CI 38.4-83.8 v 2.8/1000 hours, 95% CI 1.8-5.2, P<0.001). Re-injuries constituted 6.1% (55/907) of all injuries and caused longer absences than initial injury (15 vs 9). A total of 907 injuries were recorded. No significant differences were found between overall (P=0.935), training (P=0.752) and match (P=0.882) incidence and muscle (P=0.728) and ligament (P=0.991) injuries between seasons. There was a significant increase in the number of hamstring injuries occurring during match play across seasons (R2=0.450, b=0.575, 95% CI 0.1 to 1.1, P=0.024). Moderate severity injuries accounted for 32.6% of all injuries (21-45.5%, 296/907), with a mean (SD) time loss of 18 (33) days per injury. Conclusions Whilst overall incidence rates remain stable; the incidence of hamstring injuries remains high and re-injuries had a higher severity than initial injuries. Moderate injuries were the most frequent and on average you can expect injury burden of 18 days per injury per season.

Introduction: The epidemiology of injury in male professional football has been well documented (Ekstrand, Hägglund, & Waldén, 2011) and used as a basis to understand injury trends for a number of years. The prevalence and incidence of injuries occurring in women’s super league football is unknown. The aim of this study is to estimate the prevalence and incidence of injury in an English Super League Women’s Football squad. Methods: Following ethical approval from Leeds Beckett University, players (n = 25) signed to a Women’s Super League Football club provided written informed consent to complete a self-administered injury survey. Measures of exposure, injury and performance over a 12-month period was gathered.

The epidemiology of injury in male professional football is well documented and has been used as a basis to monitor injury trends and implement injury prevention strategies. There are no systematic reviews that have investigated injury incidence in women’s professional football. Therefore, the extent of injury burden in women’s professional football remains unknown. PURPOSE: The primary aim of this study was to calculate an overall incidence rate of injury in senior female professional soccer. The secondary aims were to provide an incidence rate for training and match play. METHODS: PubMed, Discover, EBSCO, Embase and ScienceDirect electronic databases were searched from inception to September 2018. Two reviewers independently assessed study quality using the Strengthening the Reporting of Observational Studies in Epidemiology statement using a 22-item STROBE checklist. Seven prospective studies (n=1137 professional players) were combined in a pooled analysis of injury incidence using a mixed effects model. Heterogeneity was evaluated using the Cochrane Q statistic and I2. RESULTS: The epidemiological incidence proportion over one season was 0.62 (95% CI 0.59 - 0.64). Mean total incidence of injury was 3.15 (95% CI 1.54 - 4.75) injuries per 1000 hours. The mean incidence of injury during match play was 10.72 (95% CI 9.11 - 12.33) and during training was 2.21 (95% CI 0.96 - 3.45). Data analysis found a significant level of heterogeneity (total Incidence, X2 = 16.57 P < 0.05; I2 = 63.8%) and during subsequent sub group analyses in those studies reviewed (match incidence, X2 = 76.4 (d.f. = 7), P <0.05; I2 = 90.8%, training incidence, X2 = 16.97 (d.f. = 7), P < 0.05; I2 = 58.8%). Appraisal of the study methodologies revealed inconsistency in the use of injury terminology, data collection procedures and calculation of exposure by researchers. Such inconsistencies likely contribute to the large variance in the incidence and prevalence of injury reported. CONCLUSIONS: The estimated risk of sustaining at least one injury over one football season is 62%. Continued reporting of heterogeneous results in population samples limits meaningful comparison of studies. Standardising the criteria used to attribute injury and activity coupled with more accurate methods of calculating exposure will overcome such limitations.

INTRODUCTION: The epidemiology of injury in male professional football has been well documented (Ekstrand, Hägglund, & Waldén, 2011) and used as a basis to understand injury trends for a number of years. The prevalence and incidence of injuries occurring in womens super league football is unknown. The aim of this study is to estimate the prevalence and incidence of injury in an English Super League Women’s Football squad. METHODS: Following ethical approval from Leeds Beckett University, players (n = 25) signed to a Women’s Super League Football club provided written informed consent to complete a self-administered injury survey. Measures of exposure, injury and performance over a 12-month period was gathered. Participants were classified as injured if they reported a football injury that required medical attention or withdrawal from participation for one day or more. Injuries were categorised as either traumatic or overuse and whether the injury was a new injury and/or re-injury of the same anatomical site RESULTS: 43 injuries, including re-injury were reported by the 25 participants providing a clinical incidence of 1.72 injuries per player. Total incidence of injury was 10.8/1000 h (95% CI: 7.5 to 14.03). Participants were at higher risk of injury during a match compared with training (32.4 (95% CI: 15.6 to 48.4) vs 8.0 (95% CI: 5.0 to 10.85)/1000 hours, p<0.05). The most common sites of injury was the anterior thigh (13/43, 30.2%) and knee (11/43, 25%). There were eleven (25.6%) discrete quadricep muscle injuries (4 traumatic 36.4%; 7 overuse 63.6%) and eight (18.6%) discrete ligament injuries (8 traumatic 100.0%). There were two minimal injuries (4.7%; 1-3 days), twenty-five mild (58.1%; 4- 7 days), twelve moderate (27.9%; 8 – 28 days) and four severe injuries (9.3%; > 28 days) of which there were three non-contact anterior cruciate ligament (ACL) injuries. The epidemiological incidence proportion was 0.80 (95% CI: 0.64 to 0.95) and the average probability that any player on this team will sustain at least one injury was 80.0% (95% CI: 64.3% to 95.6%) CONCLUSION: This is the first report capturing exposure and injury incidence by anatomical site from a cohort of English players and is comparable to that found in Europe (6.3/1000 h (95% CI 5.4 to 7.36) Larruskain et al 2017). The number of ACL injuries highlights a potential injury burden for a squad of this size. Multi-site prospective investigations into the incidence and prevalence of injury in women’s football are required

Background The epidemiology of injury at club level in the English Women’s Domestic Club Football League is unknown. The aim of this study was to estimate the incidence, prevalence, and nature of injury in a single women’s football squad over the course of one season. Study Design Prospective single site cohort study Methods Twenty-five female footballers competing in the English Women’s Championship were observed. Data collection procedures followed the UEFA consensus guidelines (2006). Individual player exposure was recorded for all football related activity and incidence of injury per 1000h was estimated for total, match, and training activity. Prevalence, site, and type of injury was recorded. Epidemiologic incidence proportions, clinical incidence and severity was calculated to provide measures of injury burden and resource management statistics. Results A total of 18 injuries including re-injuries were sustained in 11 players providing a clinical incidence of 0.72 injuries per player. Epidemiological incidence proportion was 0.44 (95% CI: 0.24 – 0.74), thus the average probability that any player would sustain at least one injury was 44% (95% CI: 25% to 63%). The total incidence of injury was 8.0/1000h, 30.6/1000h during match play and 2.2/1000h during training. The most common sites of injury were the knee (5/18, 28%) and thigh (4/18, 22%). There was two (11%) non-time loss and 16 (89%) time-loss injuries recorded. Of the 16 time loss injuries, there were three (19%) severe, five (31%) moderate and six (37%) minor severity injuries. Of the five knee injuries, two (13%) were major severity ruptures of the anterior cruciate ligament. Injury burden was estimated to be 468 days lost/1000h. Conclusions This is the first prospective investigation capturing women’s injury incidence data from a cohort of English domestic club players. Total, match, and training incidence rate estimates are comparable to rates of single site cohort studies in Europe. The days lost from knee injuries imposes an increased burden on a squad of this size. Multi-site prospective investigations of injury are required.

Aim: To estimate the incidence of injury in adult elite women's football and to characterise the nature and anatomical location of injuries. Design: Systematic review and meta-analysis. Data sources: Combinations of the key terms were entered into the following electronic databases (PubMed, SPORTDiscus, Science Direct and Discover) from inception to May 2021. Eligibility criteria for selecting studies: (1) Used a prospective cohort design; (2) captured data on elite adult women players; (3) reported injury incidence by anatomical site; (4) captured data of at least one season or national team tournament; (5) included a definition of injury; and (6) written in English. Results: The search identified 1378 records. Twelve studies published between 1991 and 2018 were included in our review and sampled 129 teams. In domestic club football, injury incidence rate was estimated to be 5.7/1000 hours (total), 19.5/1000 hours (match) and 3.1/1000 hours (training). In tournament, football match incidence was estimated to be 55.7/1000 hours. The knee (22.8%; 368/1822) was the most common site of injury in domestic club football. The ankle (23.7%, 105/443) was the most common site of injury in tournament football. Ligament sprains were the most common type of injury (27.8%), followed by muscle strains (19.1%). Severn studies (58%) had a high risk of bias associated with exposure definition and measurement and considerable heterogeneity exists between the included studies (I2=49.7%-95%). Summary/conclusion: Ligament sprains occur more frequently in adult elite women football players. We advise caution in interpretating point estimates of the incidence of injury due to high statistical heterogeneity. Standardising injury reporting and the accurate recording of match and training exposure will overcome such limitations. PROSPERO registration number: CRD42019130407.su.

Although injury rates between elite female and male players are comparable, female players are more likely to sustain an anterior cruciate ligament (ACL) (2011, Walden et al., Knee surgery, sports traumatology, arthroscopy, 19, 11-19). A common mechanism of ACL injury is non-contact trauma sustained when landing from a jump. The Tuck Jump Assessment (TJA) uses 10 criteria to identify technique flaws when jumping and landing (2008, Myer et al., Athletic Therapy Today, 13, 39-44) although inter-rater reliability has been challenged (2016, Dudley et al., Journal of Strength and Conditioning Research, 30, 1510-1516). The aim of this study was to identify commonly occurring technique flaws during the TJA and to determine inter-rater agreement for each criterion and the composite score. Following institutional ethical approval sixty female soccer players were recruited from one international squad (mean (SD): age = 20.27 ± 3.44yrs; height = 168.02 ± 5.26cm; mass = 62.54 ± 6.33kg). Video recordings (sagittal and coronal plane) of each player undertaking the TJA on an artificial 4G playing surface were taken. Four raters (2 physiotherapists and 2 strength and conditioning coaches) independently assessed each TJA criterion post hoc (flaw present = 1 point, flaw absent = 0 points) and the composite score calculated for each player. There were 665 technique flaws. Criterion 2 ‘Thighs do not reach parallel’ was most common (N=147/665), followed by criterion 1 ‘Knee valgus on landing’ (N=80/665). Criterion 9 ‘Pause between jumps’ was least common (N=23/665).The most common fault category was ‘Knee and thigh motion’ (N=234/720, 32.5% composite of 3 criteria weighted for maximum possible faults). There were clinically acceptable levels of agreement between raters for ‘Lower extremity valgus at landing’ k = .83 (95% CI, .72 – .93); ‘Thighs do not reach parallel (peak of jump)’ k = .84 (95% CI, .74 - .94); ‘Thighs not equal side to side’ k = .86 (95% CI, .75 - .96). The level of agreement for the composite score of all 10 criteria ranged from kw = .62 (95% CI, .48 – .76) to kw = .80 (95% CI, .70 – .90) suggesting a ‘fair-to-very good’ level of inter-rater agreement. The ‘knee and thigh’ motion category of the TJA may provide the most useful information for knee mechanics and potential risk factors for knee injury. We recommend its use for screening elite female soccer players. Common technique flaws identified by the tuck jump assessment in elite female soccer players. Available from: https://www.researchgate.net/publication/312055033_Common_technique_flaws_identified_by_the_tuck_jump_assessment_in_elite_female_soccer_players [accessed Sep 22, 2017].

Injury rates between elite female and male players are comparable, although female players are more likely to sustain an anterior cruciate ligament (ACL) injury. The common mechanism of ACL injury is non-contact trauma sustained when landing from a jump. The Tuck Jump Assessment (TJA) is commonly used in football to assess jump landing technique. The aims of this study were to determine inter-rater agreement and internal consistency of the TJA and to identify commonly occurring technique flaws. Sixty elite female football players (mean (SD): age = 20.27 ± 3.44yrs) were video recorded whilst undertaking the TJA and independently assessed by four raters. Clinically acceptable levels of agreement were reached for ‘Lower extremity valgus at landing’ k = .83 (95% CI, .72 – .93); ‘Thighs do not reach parallel’ k = .84 (95% CI, .74 - .94); ‘Thighs not equal side to side’ k = .86 (95% CI, .75 - .96). The level of agreement for the composite score of all 10 criteria ranged from kw = .62 (95% CI, .48 – .76) to kw = .80 (95% CI, .70 – .90) suggesting a ‘fair-to-very good’ level of inter-rater agreement. The most common technique flaws were found for criterion 2 ‘Thighs do not reach parallel’ (N=147/665) and criterion 1 ‘Knee valgus on landing’ (N=80/665). However, internal consistency results suggest that the TJA is not unidimensional. We suggest ‘Knee valgus on landing’ may have clinical utility although further research is needed.

Although injury rates between elite female and male players are comparable, female players are more likely to sustain an anterior cruciate ligament (ACL) (Walden et al., 2011, Knee Surgery, Sports Traumatology, Arthroscopy, 19, 11–19). A common mechanism of ACL injury is non-contact trauma sustained when landing from a jump. The Tuck Jump Assessment (TJA) uses 10 criteria to identify technique flaws when jumping and landing (Myer et al., et al., 2008, Athletic Therapy Today, 13, 39–44) although interrater reliability has been challenged (Dudley et al., 2016, Journal of Strength and Conditioning Research, 30, 1510–1516). The aim of this study was to identify commonly occurring technique JOURNAL OF SPORTS SCIENCES s37 flaws during the TJA and to determine inter-rater agreement for each criterion and the composite score. Following institutional ethical approval, 60 female soccer players were recruited from one international squad (mean (SD): age = 20.27 ± 3.44 years; height = 168.02 ± 5.26 cm; mass = 62.54 ± 6.33 kg). Video recordings (sagittal and coronal plane) of each player undertaking the TJA on an artificial 4G playing surface were taken. Four raters (2 physiotherapists and 2 strength and conditioning coaches) independently assessed each TJA criterion post hoc (flaw present = 1 point, flaw absent = 0 points) and the composite score calculated for each player. There were 665 technique flaws. Criterion 2 “Thighs do not reach parallel” was most common (N = 147/665), followed by criterion 1 “Knee valgus on landing” (N = 80/665). Criterion 9 “Pause between jumps” was least common (N = 23/665).The most common fault category was “Knee and thigh motion” (N = 234/720, 32.5% composite of 3 criteria weighted for maximum possible faults). There were clinically acceptable levels of agreement between raters for “Lower extremity valgus at landing”, k = .83 (95% CI, .72–.93); “Thighs do not reach parallel (peak of jump)”, k = .84 (95% CI, .74–.94); “Thighs not equal side to side”, k = .86 (95% CI, .75–.96). The level of agreement for the composite score of all 10 criteria ranged from kw = .62 (95% CI, .48–.76) to kw = .80 (95% CI, .70–.90) suggesting a “fair-to-very good” level of inter-rater agreement. The “knee and thigh” motion category of the TJA may provide the most useful information for knee mechanics and potential risk factors for knee injury. We recommend its use for screening elite female soccer players.

Musculoskeletal injuries are common in both general and sporting populations and contribute to significant healthcare costs, lost workdays and compromised performance of daily activity and sport. Despite various rehabilitation models being available to health and rehabilitation practitioners, there are some inconsistencies in structure, terminology and specificity across these. The current narrative review critically evaluates existing rehabilitation models, frameworks and phased approaches, identifying limitations related to structure, content and specificity. Additionally, a novel multicomponent exercise rehabilitation model is proposed which adopts a non-linear, concurrent approach to attribute development and integration of progression guidance. Using a multicomponent approach, a structured yet adaptable progression framework is provided that could help optimize rehabilitation outcomes, minimize detraining and enhance individuals’ readiness for return to sport or daily activity.

Chapter 5. The Elbow: Treatment of Lateral Epicondylalgia

Travelled to Brazil with disability swimming and athletics in preparation for Rio 2016