SPORTS MEDICINE

Screening in
football players
– Written by Stephen Targett and Celeste Geertsema, Qatar

WHAT IS SCREENING? forms part of an annual health check, which of known medical conditions - to ensure
Screening is a process used in a has a wider purpose than the identification correct on-going management. This allows
population to identify unrecognised disease of individual occult disease. for optimal performance and ensures player
in individuals without signs or symptoms. The most important aspect of this safety, for example adequate control of
The World Health Organization published health check is the identification of diabetes mellitus.
guidelines for assessing a screening unknown medical conditions that might Then there is also the review of recent
programme in 1968, now called the Wilson- place an athlete at risk from participating injuries to ensure full recovery. For example:
Jungner criteria1. in football. The obvious example of this • Review of a recent ankle inversion
The key criteria are as follows: is an underlying cardiac condition that injury.
• The condition screened for should be an may place a player at risk of sudden death • Checking that there are no residual
important health problem. during exercise. However, there are many symptoms of pain, swelling or
• It should be detectable at an early stage. other conditions that also warrant regular instability.
• There should be a treatment available screening investigations. For example: lack • Checking that full range of movement,
for the condition that is of more benefit of immunity to hepatitis B in a country power and functional stability have
earlier than at a later stage. with a high prevalence of carriers of this been restored.
• The test should be acceptable to the disease is a much more common, but less • Checking that the player is complying
population. newsworthy, problem. with any on-going rehabilitation
• There should be an agreed policy on The annual health check also facilitates exercises or use of braces or taping.
who to treat. identification of unknown medical This regular check-up also allows
• The process should be cost effective. conditions that might affect performance, the opportunity to review current
• Screening tests should also be reliable, for example mild iron deficiency or exercise musculoskeletal symptoms that have
specific and sensitive. induced bronchospasm. Often players are affected performance but may not have
not aware that their lack of performance been reported to team medical staff.
WHY SCREEN FOOTBALL PLAYERS? may be attributable to a treatable illness. Finally, the screening examination can
Screening in football players (or any other A less common, but very important be used to check any current medications
sporting population for that matter) usually aspect of this annual check is a review or supplements that are being taken and

138
educate or remind the player of their schedule/following inter time zone travel Unfortunately, there is no perfect mix
responsibilities under the World Anti- or with the psychological stress of family of monitoring tools that can identify when
Doping Agency regulations and check that problems. Other changes such as a change a player will be injured. However, several
any Therapeutic Use Exemptions, which in training surface or footwear, may also methods, which are used to identify if a
allows a player to use medications which increase the risk of injury. A periodic health player is fatigued or more susceptible to
would otherwise be forbidden during sport, examination should therefore be combined injury, have been developed. Examples of
are valid. with on-going player monitoring during these include Profile of Mood Scores (POMS),
Screening assessments are traditionally the season to attempt to identify players at resting heart rate, heart rate variability or
done in the pre-season period and have increased risk of injury or illness. actigraphy (a movement sensor usually
been given a variety of titles such as carried on the wrist like a watch). Various
pre-participation examination (PPE), blood test measures of recovery such as
periodic health examination (PHE) or pre- creatine kinase, testosterone or cortisol can
competition medical assessment (PCMA).
A periodic health also be utilised. Exactly when to use these
tools, how often and what weighting to place
WHAT IS THE DIFFERENCE BETWEEN exam should be on each variable is a matter of conjecture.
SCREENING AND MONITORING? Although packages have been marketed
The annual screening examination is combined with by some companies who believe that they
only a snapshot of a player at one point in
time. It is useful for identifying an ‘at risk’ on-going player have discovered the correct formula, there
are in fact a wide variety of monitoring
player. However, there are many external
risk factors which may develop during a
monitoring to programmes employed by different teams
around the world.
season and which can predispose a player identify players at
to injury. For example, a player may become WHICH SCREENING PROGRAMME SHOULD
more susceptible to injury or illness at times risk of injury BE USED?
of increased ‘stress’, such as during periods As with on-going player monitoring,
of heavy training load or congested playing there is no universally adopted screening

SPORTS MEDICINE IN FOOTBALL TARGETED TOPIC 139

tool that suits all athletes. A comparison 1) Assessment for risk of sudden death Middle Eastern athletes to have undertaken
of the screening medical forms from (cardiac screening) cardiac screening.
FIFA, the IOC (International Olympic The near death of Fabrice Muamba, who There is, however, still no universal
Committee) and AAFP (American Academy suffered a cardiac arrest while playing for consensus regarding the value of all
of Family Physicians) pre-participation Bolton Wanders in a Premiership match available tests and their inclusion in a
health evaluation forms reveals that there early in 2012, was one of the latest in a screening programme. For example, FIFA
are a wide variety of different screening series of cardiac arrests during exercise in and UEFA recommend echocardiography
questions and clinical examination tests high profile athletes. Such incidents are as a mandatory part of the Pre-Competition
between these forms. widely covered in the media and are often Medical Assessment before European or
What should be included in a screening followed by calls for action to prevent future World Cup events, while others recommend
evaluation will largely depend upon the such occurrences. In fact, many sporting further investigations such as ECG and
sport, the available time and resources and organisations, including FIFA, UEFA (Union ECHO only when abnormalities have
also the population being screened. Clearly of European Football Associations) and the been identified on medical history and
money, staff, equipment and expertise will FA (Football Association) require annual examination. However, a comprehensive
be different for an elite professional team cardiology screening. family history, personal history and clinical
compared to community level teams and Aspetar – Qatar Orthopaedic and Sports examination are considered minimum
age group, gender or ethnic group may Medicine Hospital started its cardiac requirements by most organisations.
affect the conditions being screened for. screening programme in January 2009 and One of the challenges of using ECG
There are three main areas that are has screened over 5000 athletes with an as part of a screening programme is
traditionally considered when designing a electrocardiography included as standard distinguishing the normal physiological
screening programme. in all athletes. This is the largest cohort of changes associated with athletic training

140
 Aspetar has screened over 5000 athletes, the
largest cohort of Middle Eastern athletes to
have undertaken cardiac screening

from changes associated with cardiac regularly reported that non-injury related, in following season. This rose to 10% if
pathology. Most of the normative data are non-cardiac conditions represented 50% or they had a history of multiple previous
derived from ECGs of Caucasian athletes more of all consultations5. Some of the most ankle injuries and 9% if they had an ankle
but it is known that ethnicity can affect the common conditions include respiratory injury in the past 10 months. Furthermore,
normal ECG pattern with Black African/ illness (including exercise-induced Engebretsen et al also found that 26% of
American athletes having an increased bronchospasm), iron deficiency, allergies, ankle sprains occurred in players with no
incidence of T wave inversion, but as yet infections and skin disorders. A thorough history of ankle sprain9. Therefore when
there are insufficient normative data from pre-competition medical assessment instigating a programme to prevent ankle
other ethnic groups. The data collected by would therefore include screening for these injuries, if those with a previous history of
Aspetar on Middle Eastern athletes will be conditions. The general medical screening ankle sprains are the only ones targeted, a
invaluable in identifying any differences in assessment also allows for monitoring of significant proportion of future injuries will
this ethnic group. previously diagnosed conditions in the be missed.
Although, with experience, the number athlete and review of current medications. Other risk factors that have been
of false positive ECG’s (those interpreted This is a good opportunity to assess the suggested are clinical instability and poor
as being normal in athletes without necessity for therapeutic use exemption single leg balance10,11. However, not all
cardiac conditions) has decreased, even applications (for those athletes who need to authors agree. And one reason for this might
in the most experienced hands about 5% use prohibited medications). be that the tests for ankle instability are
of athletes will have false positive ECGs not very reliable (poor inter-tester or inter-
leading to further investigations with cost 3) Assessment for injury risk (musculoskeletal attempt reliability) or sensitive enough.
and anxiety implications. The commonest screening) Engebretsen et al found that 97.4% of their
condition detected by cardiac screening, The most common injuries in football are subjects scored normal or supranormal for
hypertrophic obstructive cardiomyopathy, hamstring tears, groin injuries, knee injuries one of their measures of ankle instability9.
has no definitive treatment and data are still (ligament, meniscal and chondral injuries) Several studies have shown that, looking
lacking to confirm that by identifying this and ankle sprains6,7. The rationale behind at a variety of sporting populations, that
group and preventing them from playing musculoskeletal screening is to identify the rate of ankle sprains can be reduced
sport will result in a significant reduction risk factors for specific injuries in individual either by neuromuscular training or with
in mortality. Cardiac screening is also athletes and then to instigate a secondary the use or orthotics or bracing, particularly
expensive. So at present, cardiac screening in prevention programme. However, there is in previously injured players12. The benefit
athletes does not meet the Wilson-Jungner still much debate about the significance of bracing or orthotics seems to be more
criteria, but with time might do so as more of various risk factors and the success of consistently effective but may not be
data are collected and false positive rates targeted prevention programmes. popular in football players as they may not
decrease. easily fit in to the modern tightly fitting,
Ankle injuries low cut football boot and therefore may
2) Assessment for illness risk (general medical The most consistently reported risk perceived to negatively affect performance.
screening) factor that is predictive for a new ankle
While there is a strong emphasis on injury in male football is a previous history Knee injuries
cardiac screening due to the potentially of ankle injury8. However, in their study As with ankle injuries, a previous
devastating consequences of sudden of Norwegian professional footballers, history of knee injury is the most reported
cardiac arrest, the incidence of non-cardiac Engebretsen et al found the positive risk factor for future knee injuries in male
medical conditions in athletes is actually predictive value (PPV) to be low, with only football players, particularly when knee
much higher. In fact, studies investigating 6% of those with a previous history of any injury rehabilitation has been inadequate13.
athlete presentations at Olympic Games ankle injury sustaining an ankle injury Other risk factors, such as quadriceps

SPORTS MEDICINE IN FOOTBALL TARGETED TOPIC 141

hamstring muscle imbalance, slow reaction hamstring injury are those at highest risk football players who present for screening
time and joint laxity have been suggested, of future injury, it may be worth the whole at Aspetar. This assessment includes
but have not been shown to be consistently team undergoing a Nordic hamstring comprehensive cardiac, general medical and
predictive in adult male football players. strengthening programme since hamstring musculoskeletal components and is ideally
Gender is also an important factor – injuries do occur in those without previous repeated annually.
studies have shown that the ACL injury rate history of injury.
in female football players to be more than WHAT IS THE FUTURE OF SCREENING?
double than that of males (and even higher Groin injuries Some controversy about screening
in girls compared with boys), the rate of As with the previously mentioned injury remains and no single screening tool can
meniscal and collateral ligament injuries to types, the most consistently reported risk be considered to be perfect. There is also
be also significantly higher in females and factor for new groin injury is a previous no value in collecting information if the
that ACL injuries tend to occur at a younger history of injury to that body part13,17. information does not lead to either direct
age in females (average 19 years) than in Strength imbalances around the pelvis have intervention for that player or is part of
males (average 23 years). also been proposed as a risk factor for groin a bigger data collection process. When
Intervention studies have shown that injuries. Engebretsen reported an increased undertaking research, the information
neuromuscular training may prevent knee risk of groin injury in those with weak should be of excellent quality and therefore
injuries, but this has not been shown in adductor muscles on clinical examination18. more tightly controlled than may currently
senior male football players14. It would Although Hölmich et al19 showed that an be the case in screening clinics. It may not
therefore seem advisable to ensure that active adductor strengthening programme be possible to extrapolate and compare
all players with a previous history of knee was effective in treating those with chronic data collected in this way between genders,
injury have successfully completed their groin pain, it remains to be proven whether age groups and levels of participation in
rehabilitation programme. this is effective at injury prevention in a different sports.
randomised controlled trial20. In summary, although our current
Hamstring injuries screening tools do not meet the Wilson-
The most significant risk factor for THE FIFA PRE-COMPETITION MEDICAL AS- Jungner criteria for a screening programme
hamstring injuries is (once again) a history SESSMENT they do provide an excellent opportunity
of prior hamstring injury, with Arnason According to the FIFA regulations, to perform an annual general medical and
reporting an odds ratio of 7.4213. Other risk all football teams involved in FIFA musculoskeletal health check. There is still
factors include older age, low hamstring competitions are encouraged to complete much scope for improvement, particularly
strength and low hamstrings to quadriceps the Pre-Competition Medical Assessment, with detecting risk factors for injury. Further
strength. including echocardiography. This is also good quality research is needed, and will no
Eccentric hamstring strengthening, the screening assessment used for all doubt influence advice in future.
using ‘Nordic hamstring’ exercises, has
been shown to reduce hamstring injury
rates. Arnason15 showed a 65% reduction
in injuries in a non-randomised study.
Petersen16 showed a 71% reduction in
hamstring injury risk, with numbers
needed to treat (NNT) being 13 players only.
What should be included
More impressively, for players with a history
of a previous hamstring strain, they showed in a screening evaluation
an 86% reduction in recurrent injuries and
calculated that to prevent one hamstring will largely depend
upon the sport, available
injury in this group you only need to get
three players to undertake the Nordic

time and resources and

142
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