Prevention of Football Injuries I

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Introduction

The ever-increasing number of football injuries in both genders and all age groups and their consequences indicate the need for proper prevention. These consequences not only have a negative influence on performance but raise recognisable socioeconomic problems. In the USA, the primary medical cost associated with football injuries is over $36 billion per year not including costs associated with the loss of competition or working days [1].

Due to the diversity of injuries and the causative risk factors, the required preventive strategy must be complex. Obviously, such a programme must be applicable for everyday practice at all skill levels of football without any prob- lems. Despite about 200 million players playing football throughout the world, there are only a few clinical trials proving the real effectiveness of com- monly used preventive measures. Until now, three studies have discussed the general preventive effects of multi-factorial injury prevention programmes [2–4], and seven others have evaluated the prevention of specific types of injury, namely, ankle sprains, severe injuries of the knee, and hamstring strains [5–11]. With the exception of one, all these publications conclude that both the general injury rate and specific types of injury can be reduced sig- nificantly by means of prevention (Table 1).

Despite scientific evidence of their success, these methods are not yet incorporated in the general training routine. Obviously, there are big differ- ences in opportunities and circumstances of prevention between the big pro- fessionals and amateur football clubs, and there are also major differences from country to country. However, the final goal should be that general con- cepts become nearly the same in different clubs and different countries and become part of the training routine.

In this chapter, we give an overview for physicians and how they can con-

tribute to and enrich scientific data on injury prevention, which can be espe-

cially applicable in the studied settings (e.g. in the club with which the physi-

cian works). Furthermore, we also present a general strategic concept that

should help to reduce the overall injury rate.

Table 1.Controlled studies on the prevention offootball injuries.ACL,anterior cruciate ligament Study AuthorsPopulation: gender, age (in years)

Sample sizeCountryType of injuryType of interventionResult Ekstrand et al. [2]Males, 17-3712 teamsSwedenAll injuriesMulti-modal intervention programme

Significantly less injuries vs. control group by 75% Heidt et al. [3]Females, 14-18300 playersUSAAll injuriesFrappier acceleration training programme

Significantly less injuries vs. control group by 59% Junge et al. [4]Males, 14-19194 playersSwitzerlandAll injuriesMulti-modal intervention programme

Significantly less injuries vs. control group by 21% Tropp et al. [5]Males, seniors296 playersSwedenAnkle sprainsUse of orthosis or ankle-disk trainingLess injuries in players with previous history of ankle sprains using either technique Surve et al. [6]Males, seniors504 playersSouth AfricaAnkle sprainsInstruction to wear a semi-rigid orthosis

Significant reduction of recurrent ankle sprains in players with previous history of ankle sprains Caraffa et al. [7]-60 teamsItalyACL injuriesProprioceptive trainingSignificant reduction of ACL injuries

Hewett et al. [8]Females, 14–19200 playersUSASerious knee injuriesPre-season neuromuscular training programme

A trend of reduced injuries in the trained v.s. control group Söderman et al. [9]Females, 21140 playersSwedenSevere knee injuries and ankle sprains

Balance-board trainingNo preventive effect Askling et al. [10]Males, 2530 playersSwedenHamstring strainsTraining with eccentric overloadSignificantly less injuries vs. control group Mandelbaum et al. [11]Females, 14–185,703 playersUSANon-contact ACL injuriesMulti-modal intervention programme

Significant reduction of ACL injuries

Study AuthorsPopulation: gender, age (in years) Sample sizeCountryType of injuryType of interventionResult

How to Assess the Possibilities of Injury Prevention?

Preventive measures in football – just like in any other sport – should be based on epidemiological research. Van Mechelen et al. suggested in 1992 that measures to prevent sports injuries should follow what they called a

“sequence of prevention” [12]:

1. Identify the extent of the problem of injuries in football (hazard identifi- cation)

2. Identify the potential influential factors and mechanisms (risk assess- ment)

3. Introduce preventive measures that are likely to reduce the future risk and/or severity of injuries (risk minimisation)

4. Re-evaluate the maintenance of injury records being crucial, allowing the effectiveness of preventive measures and implemented management plans to be assessed (re-assessment).

Step One: Extent of the Injury Problem – Hazard Identification

Firstly, the extent of the injury problem should be identified and described.

This first step of the sequence features two cornerstones of the whole preven- tion concept. One of these cornerstones is the use of standardised definitions for injury and especially for the description of the extent of the problem – injury incidence. The injury incidence should be expressed as the number of injuries per exposure time, usually per 10,000 h of participation. The lack of use of standard definitions and the shortage of reliable detailed epidemiolog- ical data hinders us gaining real evidence-based results, and it is furthermore the main obstruction to summarising the outcome of different studies by means of valuable meta-analyses.

On the other hand, any study of any size provides most benefits for the studied population – e.g. for a club – for any results hat study are most appli- cable to similar circumstances. This is one reason that there are not only great differences between subgroups of different ages, skill levels, and gender, but other important conditions varying from country to country must be consid- ered. Thus, a fundamentally sound study helps the work of all professionals involved in the game but most of all the work of the experts carrying out the particular study.

Step Two: Potential Risk Factors and Mechanisms – Risk Assessment

The second step is to identify factors and mechanisms that play a part in

injury occurrence. As there is always a complete interaction between these

factors, the cause of injury is often multi-factorial. At the same time, most risk

factors cannot be associated with only one or two types of injuries. In accor-

dance with the diversity of injuries in football, there are numerous risk fac- tors, with changing levels of evidence proving their role in the development of a certain injury. (Read more about Risk Factor in Chapter 1).

However, there are already many factors that are identified by means of evi- dence-based medicine as important risk factors for numerous injuries, such as joint flexibility including pathological ligamentous laxity and muscle tightness [13], mechanical and functional joint instability [14–16], and some previous injuries and inadequate rehabilitation methods [15]. Causative extrinsic risk factors include training load [17], inadequate equipment (shin guards, taping, shoes), [2, 6, 14, 18, 19], playing field conditions [14–17], and foul play [20].

The present knowledge regarding risk factors seems to be biased by selec- tion according to age, gender, and nature and level of play. In order to apply more effective preventive measures, the complex interaction of intrinsic (per- son-related) and extrinsic (environment-related) risk factors should be clari- fied, and their gender, age, and level specificity should be identified [21].

Step Three: Measures of Injury Prevention – Risk Minimisation

The third step is to introduce preventive measures. These measures should be based on aetiological factors and mechanisms, as identified in the second step. We should note here that addressing intrinsic risk factors reduces the incidence and severity of non-contact injuries (both acute and overuse) while consequences of direct trauma are generally reduced by the elimination of extrinsic risk factors.

As there are numerous risk factors, there are even more ways to address them. Below we give only a short overview of measurements according to the competence of different persons and bodies concerned with the game (Table 2).

Coach’s Responsibilities

The coach has the main responsibility for the athletes’ safety. They must teach them safety principles and appropriate football skills and ensure they are always in adequate condition. The coach should also master basic skills in the management of acute sports injuries. Besides the late season, injuries peak during pre-season practices [3, 10, 22]. All activities should be well controlled at this time, and coaching should apply injury-safe techniques and put a spe- cial focus on methods, which help injury prevention not just for the pre-sea- son but the whole season. Not allowing the athlete’s body to recover properly from training will eventually result in injury. The footballer’s body needs time to rebuild itself to a stronger level before the next training session.

Remember: athletes are not training when they are training, they are training

when they are recovering! Sleep is also an important part of training. If they

are not getting enough, get it sorted out!

Football players should participate in a well-supervised pre-season physi- cal conditioning programme as well as focusing on cardio-respiratory stami- na and good muscular condition (strength, dynamic power, endurance, flexi- bility, and proprioception). This should be started at least 6 weeks before the start of daily football practice so players will be in proper physical condition before the first day of practice. The conditioning programme should also include sports-specific exercises to prevent injury. Players should especially emphasise well-balanced strength and flexibility exercises for the lower back, abdominal muscles, and muscles of the lower extremity. Intensity, duration, and frequency of conditioning and skill practicing sessions should be increased gradually in order to prevent overuse injuries.

A similarly complex in-season conditioning programme should be fol- lowed during the course of the football season as well [3]. However, resist- ance-training programmes, which should help to prevent injuries by improv-

Trainers’perspective

Risk-conscious ed- ucation of players

Structured, complex pre- and in-season training regimen (including proper complex muscle management and stamina training) Appropriate warm up and cool down Reduction of physi- cal overload; appro- priate game/train- ing relationship

Medical perspective

Supervision of in- jury prevention; im- plementation and control of preven- tive measures

Risk-conscious atti- tude towards play- ers; education of all staff members

Load-control: assis- tance to trainings Pre-season and pre- signing examina- tions. Sufficient re- gard for complaints, ensuring sufficient recovery time and adequate rehabilita- tion

Players’ perspective

Co-operation with coaches, medical personnel, and management in re- alising the concept of injury prevention Injury-conscious play ing attitude:

hard, but fair

Good equipment, especially boots Using protective gear (shin guards, ankle taping, and bracing)

Others (officials, governing bodies) Injury awareness of clubs and governing bodies

Ensure safe pitch conditions

Observance of the existing rules Improvement of rules of the game Reduction of foul play

Table 2.Preventive measures from different perspectives and competences

ing muscle balance, may also lead to injuries when they are not properly applied or supervised. Thus, in order to avoid injury, an athletic trainer with a thorough understanding of resistance training should supervise condition- ing sessions personally. Before exercises, athletes should warm up (by means of stretching and low-intensity aerobic exercises) for more than 5–10 min.

Particular muscle groups need to be conditioned only 2–3 times weekly to allow enough time for recovery and work-load adaptation between training sessions.

Stretching [2, 13, 23, 24] and proprioceptive training [5–7, 23, 25–27] ses- sions must be held on a regular basis and are best supervised by the athletic trainer. All training regimens should be defined for each player individually;

competition among players regarding conditioning results should be discour- aged.

Warming up is often overlooked but should be part of any injury-preven- tion routine [17, 24]. A good warm up will increase the temperature of mus- cles, blood flow and oxygen supply to the muscles, the speed of nerve impuls- es, and the range of motion at joints. It not only helps to avoid injury but also improves performance. The warm up should last between 15 and 30 min but must not be carried out too early; the benefits are lost after about 30 min of inactivity. Athletes should also implement a short warm-up session in case of any prolonged breaks (half time, etc.).

Similarly to the warm up, there must be a cool down after every practice session or game played [2, 17, 27–29]. Immediately stopping vigorous activi- ties will cause a fast reduction of blood flow in the muscles, hindering the necessary transport of potentially harmful metabolites (hyperoxides, lactic acids, etc.) from the muscles. The cool down should consist of a gentle jog fol- lowed by light stretching.

Medical Perspectives – The Physician’s Responsibilities

First of all, the most important role of a physician is to supervise and coordi- nate injury prevention, to implement preventive measures both for the team and for each individual, and to asses the effectiveness of the employed meas- ures.

Wherever possible, teams should be encouraged to employ the services of athletic trainers or physical therapists who can assist the team physician in instituting and monitoring pre-participation fitness programmes [30]

Furthermore, better education of coaches and players regarding injury pre-

vention strategies is the responsibility of the physician in order to help them

include such interventions as part of their regular training programmes and

to increase general injury awareness among team members [29, 31].The team

physician should help players and coaches/athletic trainers by means of load

control, especially in the off-season. This includes detailed testing of cardio-

respiratory functions (using treadmill tests) and isokinetic dynamometric tests on the muscles of the lower extremities before starting and at the end of the pre-season conditioning period. Where appropriate, a previous injury should be addressed with an exercise programme.

The regular pre-participation examination is a basic component of foot- ball players’ care and thus provides the best opportunity for individual injury prevention. The main goals of this examination are to assess (evaluate) over- all health, detect conditions that may cause injury or that may disqualify the player from participating in the game, assess fitness, and make recommenda- tions for the exercise programme. When a player signs with a new club, a sim- ilar screening should be performed, not only to avoid legal conflicts but also with the same goals as the pre-season examination [22, 30]. These examina- tions may include on demand (e.g. a recurrent overuse injury) a biomechan- ical analysis, which can help identify possible injury risks and the need for orthotic devices as necessary.

To minimise frequency of re-injury, new injuries must be addressed and managed properly, with rehabilitation of the appropriate intensity, quality, and length. Players must not be allowed to return to football until injuries are healed, range of motion is restored, and strength has been recovered. Proper rehabilitation may break the injury/re-injury cycle but only when the pro- gramme emphasises and attains a return to full function, not just symptom relief. The team physician must make sure injured players follow the rehabil- itation prescription [14–16, 32].

Another important medical perspective is nutrition and hydration. Proper nutrition is important while good hydration is a fundamental factor in per- formance. A balanced diet is what should be aimed for: carbohydrates are important for re-fuelling muscles, protein re-builds muscles, and vitamins and minerals are required for a number of reasons related to recovery. If play- ers become dehydrated, then less blood will flow through muscles, and the muscles will be more prone to injury. This should be avoided by using iso- tonic liquids before, during, and after sports activities for water intake.

Not only physicians but everyone on the club’s staff should strictly follow anti-doping and anti-drug policies. Players must not be allowed to use steroids or any other performance-enhancing drugs! Be aware of the use of alcohol and recreational drugs.

Players’ Responsibilities

Players must co-operate with conditioning programmes and coaches to

improve the correct execution of sport-specific drills and techniques, wear

protective equipment in all contact situations, and follow the rules in order

reduce the risk of injury. They are obliged to report all, even minor, injuries

to the coaching and/or medical staff and should show full compliance with

any injury treatment or rehabilitation programme. They should gain a pro- fessional, injury-conscious attitude without losing competitiveness – thus they should play hard but fair!

Each player should have and use equipment of good quality and condition.

Shoes are the most important of any sports equipment in the prevention of overuse injuries to the lower leg. The ideal football boot should have a rigid heel counter, good depth in the upper, a flexible forefoot, a wide sole, and be slightly curved in shape; it should absorb shock well, be light and flexible, and have enough but not too much grip on the actual surface (different boots with different studding for different surface and weather conditions). If there is not enough support to the arches, insoles are recommended [22]. However, football boots should be used for sport-specific training sessions only; they are not suitable for other purposes, such as, for example, endurance training (running).

The use of shin guards is one of the first preventive measurements applied in football. They were introduced to reduce acute contact injuries to the shin.

They cannot prevent all types of shin injuries (e.g. fractures) but can reduce their severity [19].

Ankle protection (braces and taping) is another evidence-based preventive measure, hindering the development of acute sprains and thus the develop- ment of chronic instability as well [2, 14, 15, 18, 25]. Knee braces are not applied as often for prevention but mostly to reduce the adverse effect of a previous ligament injury.

Clubs’ Responsibilities

The management of a club must provide all fundamentals (human resources and financial background) to enable the ideal injury prevention concept to become practice. Clubs must realise the importance of their players (the play- er is the club’s asset) and follow the total loss approach, avoiding injuries.

Clubs should be totally committed to optimising the medical welfare of play- ers of all ages and abilities. To ensure the health and safety of players, every effort must be made to further advance the practices involved with the pre- vention of injuries.

Each club should build a professional staff responsible for the manage- ment and prevention of sports injuries, capable of effectively assisting the coaching and conditioning staff in controlling the workload, and who can individualise the conditioning programme. At least one member of this staff should be present at all practices and all games. It is the club’s responsibility to provide enough financial support to allow the medical team to work prop- erly and effectively [22].

Good playing-field conditions represent another of the club’s responsibili-

ty. Pitches should be well maintained and be free of holes or other hazards.

Clubs should prefer playing fields covered with natural grass over artificial turf, for there is a higher incidence of injuries reported on artificial playing surfaces [14–16, 25].

Officials’ Responsibilities

All officials concerned with the game must keep in mind the health and safety of the players as the overall first priority. The sport’s governing bodies and their delegated officials must have an injury-awareness approach and should continuously promote player safety at all levels. Football rules should be con- tinuously evaluated to see whether they could be altered to help to reduce the frequency of injuries. Changes, which could be applied specifically to different genders or age groups, should be strictly enforced and then re-assessed, whether they have led to the desired decrease in the number of injuries or not.

Reviews by the International Football Federation (FIFA) referees have already required them to use stricter judgement on player-to-player chal- lenges relating to the use of elbows and tackling from behind. It is expected that these changes will reduce the overall number of injuries [33].

Step Four: Controlling the Effects of the Employed Measures – Re-Assessment Evaluate the effects of preventive measures and implemented management plans by re-assessing the incidence of injury by repeating step one. This step is often overlooked, but in fact, this proves if any measure had a real preven- tive effect. Furthermore, without re-assessing the incidence of a certain injury, methods of prevention cannot be improved.

Most Important Preventive Measures

After reviewing current available literature, we can state that the implemen-

tation of a complex injury-prevention training programme is an effective strat-

egy for addressing multiple risk factors. In fact, these programmes seem to

decrease or eliminate risk factors associated with the largest number of fre-

quent football injuries (Table 3). However, incorporating elements of a com-

plex prevention strategy is not all that can and should be done. Considering

special problems of male and female soccer and youth, adult, and senior lev-

els, physicians have to assess the injury problem further by means of the 4-

step sequence of prevention. By so doing, we not only provide individualised

help to our athletes but also contribute to the establishment of a broader,

more evidence-based knowledge on the nature and prevention of injuries in

football.

Conclusions

Although it is considered to be the cornerstone of the prevention cycle, epi- demiological information on football injuries is inconsistent and far from complete. Documenting incidence of and exposure to football injuries is vital in identifying the most serious problems and detecting their risk factors in order to design proper preventive measures [12].

In the future, well-designed, randomised studies are needed on preventive actions and devices that are in common use, such as pre-season medical screenings, warming up, proprioceptive training, stretching, muscle strength- ening, taping, protective equipment, rehabilitation programmes, and educa- tion interventions (such as increasing general injury awareness among team members). The effect of a planned rule change on the injury risk in football could be tested via randomised, controlled trials before execution of the change [34].

Table 3.Features of a multi-modal strategy for the prevention of football injuries. ACL, anterior cruciate ligament

Preventive measures

Cardiovascular stamina training

Proprioceptive training including:

- Sport-specific agility drills - Core proprioception

- Lower-extremity proprioception

Stretching

Muscle strengthening – thigh muscles

Muscle strengthening – lumbar spine and back muscles

Addressed risk factor/effect Better oxygen supply

Less fatigue – improved stamina

Better neuromuscular co-ordination: less injuries associated with landing and pivot- ing drills

More muscular support to joints Fewer ACL and ankle injuries Increased muscle flexibility

Muscles become more resistant to passive forces

Less muscle injuries

Better hamstring-to-quadriceps power ra- tio (at least 2:3), better muscular balance Fewer injuries to thigh muscles

Better muscular balance; stronger deep back muscles

Less low-back pain Less groin injuries

Because the aetiology of football injuries may differ between different subgroups of the football population, different subgroups of football players (especially females and juniors) may need different prophylactic programmes to achieve a major reduction in the incidence and severity of injuries.

Establishing a good surveillance system is inevitable from this point of view as well. Through this type of analysis, risks can be identified systematically and objectives and performance standards can be established and prioritised.

The practical implications of preventive strategies need to be thought through so as to avoid conflict with other demands in football. However, in this very challenging and vital quest to reduce injuries, every participant around the game – from players to coaches, from physicians to physiothera- pists, and from governing bodies to clubs – must follow their well-defined roles.

References

1. De Loes M (1990) Medical treatment and costs of sports-related injuries in a total population. Int J Sports Med 11:66–72

2. Ekstrand J, Gillquist J, Liljedahl SO (1983) Prevention of soccer injuries. Supervision by doctor and physiotherapist. Am J Sports Med 11:116–120

3. Heidt RS Jr, Sweeterman LM, Carlonas RL et al (2000) Avoidance of soccer injuries with preseason conditioning. Am J Sports Med 28:659–662

4. Junge A, Rosch D, Peterson L et al (2002) Prevention of soccer injuries: a prospecti- ve intervention study in youth amateur players. Am J Sports Med 30:652–659 5. Tropp H, Askling C, Gillquist J (1985) Prevention of ankle sprains. Am J Sports Med

13:259–262

6. Surve I, Schwellnus MP, Noakes T, Lombard C (1994) A fivefold reduction in the inci- dence of recurrent ankle sprains in soccer players using the Sport-Stirrup orthosis.

Am J Sports Med 22:601–606

7. Caraffa A, Cerulli G, Projetti M et al (1996) Prevention of anterior cruciate ligament injuries in soccer. A prospective controlled study of proprioceptive training. Knee Surg Sports Traumatol Arthrosc 4:19–21

8. Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR (1999) The effect of neuromu- scular training on the incidence of knee injury in female athletes. A prospective study. Am J Sports Med 27:699–706

9. Söderman K, Werner S, Pietila T et al (2000) Balance board training: prevention of traumatic injuries of the lower extremities in female soccer players? A prospective randomized intervention study. Knee Surg Sports Traumatol Arthrosc 8:356–363 10. Askling C, Karlsson J, Thortensson A (2003) Hamstring injury occurrence in elite

soccer players after preseason strength training with eccentric overload. Scand J Med Sci Sports 13:244–250

11. Mandelbaum BR, Silvers HJ, Watanabe DS et al (2005) Effectiveness of a neuromu- scular and proprioceptive training program in preventing anterior cruciate liga- ment injuries in female athletes. Am J Sports Med 33:1003–1010

12. Van Mechelen W, Hlobil H, Kemper HC (1992) Incidence, severity, aetiology and prevention of sports injuries. A review of concepts. Sports Med 14:82–99

13. Witvrouw E, Danneels L, Asselman P et al (2003) Muscle flexibility as a risk factor for developing muscle injuries in male professional soccer players. A prospective study. Am J Sports Med 31:41–46

14. Ekstrand J, Gillquist J (1983) The avoidability of soccer injuries. Int J Sports Med 4:124–128

15. Inklaar H (1994) Soccer injuries. II: Aetiology and prevention. Sports Med 18:81–93 16. Arnason A, Gudmundsson A, Dahl HA, Johannsson E (1996) Soccer injuries in

Iceland. Scand J Med Sci Sports 6:40–45

17. Ekstrand J, Gillquist J, Moller M et al (1983) Incidence of soccer injuries and their relation to training and team success. Am J Sports Med 11:63–67

18. Ekstrand J, Gillquist J (1983) Soccer injuries and their mechanisms: a prospective study. Med Sci Sports Exerc 15:267–270

19. Francisco AC, Nightingale RW, Guilak F et al (2000) Comparison of soccer shin guards in preventing tibia fracture. Am J Sports Med 28:227–233

20. Hawkins RD, Fuller CW (1996) Risk assessment in professional football: an exami- nation of accidents and incidents in the 1994 World Cup finals. Br J Sports Med 30:165–170

21. Inklaar H (1994) Soccer injuries. I: Incidence and severity. Sports Med 18:55–73 22. Ekstrand J, Karlsson J, Hodson A (eds) (2003) Football medicine. Martin Dunitz,

London

23. Schmidt-Olsen S, Bunemann LK, Lade V, Brassoe JO (1985) Soccer injuries of youth.

Br J Sports Med 19:161–164

24. Agre JC, Baxter TL (1987) Musculoskeletal profile of male collegiate soccer players.

Arch Phys Med Rehabil 68:147–150

25. Ekstrand J, Nigg BM (1989) Surface-related injuries in soccer. Sports Med 8:56–62 26. Blaser KU, Aeschlimann A (1992) [Accidental injuries in soccer]. Schweiz Z

Sportmed 40:7–11

27. Engstrom BK, Renström PA (1998) How can injuries be prevented in the World Cup soccer athlete? Clin Sports Med 17:755–768

28. Hawkins RD, Fuller CW (1999) A prospective epidemiological study of injuries in four English professional football clubs. Br J Sports Med 33:196–203

29. Dvorak J, Junge A, Chomiak J et al (2000) Risk factor analysis for injuries in football players. Possibilities for a prevention program. Am J Sports Med 28:69–74

30. Micheli L, Smith A, Bachl N et al (eds) (2001) F.I.M.S. team physician manual.

Lippincott Williams & Wilkins, Asia Ltd, Hong Kong

31. Hawkins RD, Hulse MA, Wilkinson C et al (2001) The association football medical research programme: an audit of injuries in professional football. Br J Sports Med 35:43–47

32. Nielsen AB, Yde J (1989) Epidemiology and traumatology of injuries in soccer. Am J Sports Med 17:803–807

33. Hawkins RD, Fuller CW (1998) An examination of the frequency and severity of injuries and incidents at three levels of professional football. Br J Sports Med 32:326–332

34. Parkkari J, Kujala UM, Kannus P (2001) Is it possible to prevent sports injuries?

Review of controlled clinical trials and recommendations for future work. Sports Med 31:985–995