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Who is to blame for all the football injuries?

20 Jun, 12 | by Karim Khan

John Orchard, BJSM guest blog (@DrJohnOrchard)

Another major football tournament is on – Euro 2012 – and those following the England team keep reading (yet again) about the number of injured players. Why do injuries seem to be more prevalent than ever if our professionalism is supposedly improving?

In trying to answer this question, why not start with elephant in the room? The players are expected to play too much football, with not enough time for recovery. The marketing and finance gurus, who seem to be charge of scheduling games and tournaments without much input from a sports science and medicine perspective, don’t seem to have much sympathy for multimillion pound players, as long as there are enough of them to replace those who fall by the wayside due to injury. The club managers, who can face the sack if their teams don’t win enough games, also don’t have much sympathy for the national team managers, who are under exactly the same pressure, and vice versa. It apparently is on the agenda to try to reduce the number of games that a top player is expected to participate in annually, but it is tough to find a solution when clubs have so many important competitions and the national teams also want to use their best players at every opportunity.

So if you are a sports medicine professional working for one of the clubs or countries, do you just throw your hands in the air and declare that due to forces beyond your control there is little you can do about your club/country’s injury crisis?

There are a few experts around who believe that sports science & medicine staff should take matters more into their own hands and exert more pressure on managers to load players less at training and give them more time off with rotation, which (as common sense and science would dictate) would hopefully lead to lower injury rates. One of the most outspoken experts is Raymond Verheijen, who has publicly castigated medical and fitness teams for not doing enough to balance match and training loads in players1. Many other sports medicine and science experts in the football world would partially agree with his views (that footballers train too hard and play too often) but would deny his assertion that individual practitioners have the power to easily change these factors.

Is there a plausible explanation as to why the majority of teams might be pursuing a strategy of training players too much and failing to rotate their teams enough? An examination of the culture within football might provide an answer. One of the universal aspects of the “football culture” is that the manager is all-powerful and virtually-all-accountable. Part of the “all-powerful” bit means that if there is a dispute between the manager and a doctor, physio or conditioner that the manager can pull rank and resolve the dispute in his favour. It is tempting to also suggest that the manager is “fully accountable” for results and in most cases this is true (i.e. if he doesn’t win enough games he often will face the sack). In the face of results which seem unacceptable (i.e. most of the time to fans and media with optimistic expectations), the manager usually has very few “get out of jail” cards. Perhaps one of the few he does have to regularly fall back on is that “too many of our top players were injured and hence we didn’t get the results we would have expected”.  This one possibly will wash to an extent with the board and the fans, as there is still a common view that injuries are generally random and therefore out of a manager’s control. This may explain a paradox in the way that managers manage. Although you would expect a rational manager to try to avoid injuries where possible (which would improve team performance), by doing so he might sacrificing a valuable “get out of jail” card. To illustrate further, on reading that Manchester United had many injuries2 in season 2011-12, do you think that the public reputation of Sir Alex Ferguson is more enhanced (that he almost won the league despite a horrendous injury toll) or diminished (that he oversaw a regime where too many injuries occurred)? My guess is the former.

Let’s take a few hypothetical (but close to reality) graphs of the relationship between training load on the x-axis and player fitness, team injury rate and team performance (fitness minus injury rate) on the y-axis (Figure 1).

Figure 1 – Relationship of training loads (‘x’ axis) to team fitness, performance and injuries (‘y’ axis)

The science and our experience would tend to agree with the general shapes of these curves, although it is impossible to put actual numbers on the data points in real life. Also, it goes without saying that loading is far more complicated (types of training, length, intensity, rest periods, injury layoffs, cycling etc) than a simple linear x-axis. However, please bear with the reduction of all the complexity to a simple x-axis for the sake of this hypothetical.  With respect to the red curve (‘team fitness’), it is true that to a point, the harder you train the fitter you will become, although at some stage, e.g. zone 6 on the x-axis, overtraining will kick in and further training will actually be detrimental to fitness. With respect to the green curve (‘injury rate’), if you are unfit you will get a lot of injuries but if athletes train too hard3-6 (or play too much7 or often8) they will also get more injuries when compared to more moderate training regimes. If team performance (blue curve) is a combination of fitness minus injuries9, then in theory the best zone for overall team performance might be zone 4 on the graph. However, for a manager operating in the ‘real world’, where he may be sacked if his team loses games and he can’t come up with an acceptable excuse, zone 5 may be a preferable target, even if it means a detrimental performance compared to zone 4.

If you are a team doctor or physiotherapist, your KPI (“key performance indicator” in business jargon) should theoretically relate to the green curve on the graph (injuries) and you might even be more comfortable with a training load in zone 3, which could put you at odds with the manager who prefers zone 5. Again, it is worth emphasising that in the real world, a good medico would not tend to suggest a blanket reduction of all training, but would look at individual risks for injury and try to set specific training limits for those players most at risk of becoming injury or worsening a pre-existing injury. From a coaching perspective, the perception of this professional approach may still be that it is an attempt at blanket load reduction (as in “the medical staff want to stop me from training/selecting my players as much as I’d like”). How much a staff member wants to try to butt heads with someone who has ultimate power to hire-and-fire may determine how much the issue gets pressed about lowering the training loads of certain players (or rotating the players more often in matches). It certainly doesn’t make you feel any bolder if you hear about some of the high profile EPL team medical staff members who have left their clubs recently, perhaps for standing their ground to the manager about trying to prevent injuries, when maybe those who have yielded more easily still survive to tell the tale. On the topic of the ‘real world’, medical staff often have the sneaking suspicion that the only KPI that matters is keeping in the good books of the manager and doing basically whatever he dictates.

I understand the need to make managers accountable, but also feel that the power base between the managers and medical staff at football clubs is slanted far too much in the managers’ favour9. In one sense, I partially agree with the criticisms of Verheijen, but on the other hand I can see why there needs to be a major culture shift before individuals at football teams can institute much of a change. That is, it is not necessarily the fault of the medical staff that they don’t have enough influence at football clubs.

Until the culture can be shifted, perhaps high injury rates may be relatively inevitable in most football teams, both at club and national level.


  1. Veysey, W. Amateurish & prehistoric: Russia coach Verheijen slams England’s Euro 2012 preparations. 
  2. Miller, A. Manchester City top the ‘injury league’, with Manchester United bottom. 
  3. Gabbett TJ, Ullah S. Relationship between running loads and soft-tissue injury in elite team sport athletes. J Strength Cond Res 2012 Apr;26(4):953-60.
  4. Gabbett TJ, Jenkins DG. Relationship between training load and injury in professional rugby league players. J Sci Med Sport 2011 May;14(3):204-9.
  5. Gabbett TJ. The development and application of an injury prediction model for noncontact, soft-tissue injuries in elite collision sport athletes. J Strength Cond Res 2010 Oct;24(10):2593-603.
  6. Orchard J. Understanding some of the risks for soft tissue inury–a Malcolm Blight legacy? J Sci Med Sport. 2002 Jun;5(2):v-vii. 
  7. Orchard JW, James T, Portus M, Kountouris A, Dennis R. Fast bowlers in cricket demonstrate up to 3- to 4-week delay between high workloads and increased risk of injury. Am J Sports Med 2009 Jun;37(6):1186-92
  8. Dupont G, Nedelec M, McCall A, McCormack D, Berthoin S, Wisløff U. Effect of 2 soccer matches in a week on physical performance and injury rate.  Am J Sports Med 2010 Sep;38(9):1752-8.
  9. Orchard JW. On the value of team medical staff: can the “Moneyball” approach be applied to injuries in professional football? Br J Sports Med 2009 Dec;43(13):963-5. (Free Online)

John Orchard is an Australian sports physician who has worked with numerous professional team sports, but none in the EPL — for that league he is only an armchair expert. His sometimes controversial views are personal and not necessarily representative of organisations he is affiliated with. You can read more at and/or follow @DrJohnOrchard on Twitter


The beauty of social media….(4 hours after the original blog post)

A reader just alerted us to Jan Ekstrand’s paper supporting the hypothetical graph above with data. We’d be  breaking copyright to post the PDF so we can’t do that but you can read the abstract here on PubMed.

Am J Sports Med. 1983 Mar-Apr;11(2):63-7.

Incidence of soccer injuries and their relation to training and team success.

Tips for authors – what does BJSM accept?

17 Apr, 11 | by Karim Khan

BJSM has a mission to provide clinically-relevant material for clinicians in the broad field of sport and exercise medicine. BJSM aims to serve member societies such as BASEM (UK), AMSSM (US), ACSP (Australia and New Zealand), SASMA (South Africa) SSPTA (Switzerland) and ECOSEP (Europe). Will your paper be of interest to those readers? Because we receive 1000 papers annually, and can only publish about 8-10 original submissions in each of our 16 issues annually, our acceptance of original submissions is limited to around 150 per year – say 10-15%.

Thus, to help authors, we only send 40% of submissions out for external peer review. The editor and deputy editors (Khan, Pluim, Cook) screen papers for (i) relevance to our field and (ii) study design. Papers that are unlikely to be of interest to the target audience and those with a design that is open to biased conclusions are redirected to authors rapidly so they can be submitted elsewhere. Thus, recent acceptances show fewer cross-sectional studies. Case series and case reports are not part of BJSM anymore but the BMJ has its own Case Reports journal ‘BMJ Case Reports’ which is proving wildly popular.

We appreciate that many ‘publishable’ papers cannot fit inside our small envelope but fortunately there are many good journals in our field. We are always delighted to see papers that didn’t make it through our filter show up in associated sports medicine and physiotherapy journals. And one paper we rejected was resubmitted to BMJ and got published there! Great news! Peer review has limitations and has more than an element of subjectivity.

Clinical relevance, superior quality study designs where appropriate. Studies that clinicians can build on or that influence policy. BJSM is aiming for impact – in the true sense of that word!

Thanks for considering BJSM and keep those high-quality submissions coming!

What the BJSM editors look for in a paper – clinical relevance

1 Mar, 11 | by Karim Khan

BJSM is transparent about its peer-review process. We receive 1000 papers a year and can only publish about 10% of them. So 60% of papers are returned to authors after the editorial team has reviewed them. Who’s the editorial team? It’s Karim Khan, Babette Pluim and Jill Cook. So these are called ‘rejected without external review’. This should happen within a week of submission so the good news is that if the paper doesn’t look like having a chance to get into BJSM, authors have it back without delay.

Today, I’ll focus on what it takes to get through that first hurdle – to have a paper sent for external review. BJSM’s mission is to provide clinically useful material for clinicians the world over. Our summary slogan could be ‘clinically-relevant’ and ‘global/international’. Will your paper influence practice or policy in sport and exercise medicine? There are many ways to do that so we have a broad scope. Our member societies include BASEM, AMSSM, ECOSEP and the Swiss Sports Physiotherapy Association so papers should be of interest to those readers.

We are also endorsed by sports and exercise medicine societies in South Africa (SASMA), Australia and New Zealand (ACSP) so BJSM has wide reach. Our plan to focus on clinical relevance came after consultation with folks from all our member societies. We are executing a strategy which has us aiming to provide multimedia value to clinicians as they practice every day and work with active individuals in various settings. (Hence the videos and podcasts on the home page).

Sports clinicians are involved in public health so papers about physical activity and health are clearly relevant. Papers that will influence decision-makers in the field of exercise and health are also important. Data that will help teams perform better in relation to health issues are grist for the mill. But if you have a new ‘play’ in basketball that would fit better in a coaching or coaching science journals.

If you are interested in the peer-review process, see the BMJ ‘Head to Head’ (two articles, one for, one against ‘open’ peer review). Also, BJSM has a take on innovation and the problems that researchers have in challenging conventional thinking.

I’ll clarify this more about BJSM’s process in the next few days among our other blog topics. Feel free to ask questions or to comment.

Submitting a Randomised Trial? Follow the CONSORT checklist

2 May, 08 | by Karim Khan

The editorial team is delighted to receive randomised controlled trials. Please remember to use the CONSORT checklist and to incorporate as many elements as you can. Our aim is that all RCTs published in BJSM conform to the CONSORT statement.

CONSORT, stands for Consolidated Standards of Reporting Trials. The CONSORT Statement is an evidence-based, minimum set of recommendations for reporting RCTs. It helps you prepare your paper for submission. The CONSORT Statement comprises a 22-item checklist and a flow diagram, along with some brief descriptive text. The checklist items focus on reporting how the trial was designed, analyzed, and interpreted; the flow diagram displays the progress of all participants through the trial. The Statement has been translated into several languages.

You might also be interested in the EQUATOR network website. This website simplifies good reporting of health research. The resources are aimed at authors, reviewers, and developers of reporting guidelines. The website features a collection of reporting guidelines that includes:

  • CONSORT Statement (for reporting randomised controlled trials, as above)
  • QUOROM, recently renamed PRISMA (for reporting systematic reviews and meta-analyses of randomised trials)
  • STROBE Statement (for reporting observational studies)
  • STARD Statement (for reporting diagnostic accuracy studies) and many other guidelines identified through extensive literature searches.

Early days

20 Feb, 08 | by Karim Khan

I am very excited and most grateful that 6 international leaders in sports and exercise medicine have agreed to serve as Senior Associate Editors in Chief – Babette Pluim (Netherlands), Jill Cook (Australia), Liza Arendt (US), Steven Stovitz (US), Roald Bahr (Norway) and Timothy Noakes (South Africa).

This senior leadership group and I will take the first 5 months of the year to catch up with the hardworking Editorial Board and engage all those who wish to contribute to the Journal.The new Associate Editors and the expanded Editorial Board will be listed in the June issue of BJSM.

To contribute to the direction of BJSM, I encourage you to provide input either in person (e.g., The RendezVous Conference in Las Vegas (March 25-29), my visit to various UK centres in early May) or on email (

The BJSM vision that aims to reflect the diverse interests of the world of sport and exercise medicine will be on the web by June 1st.

We aim to make the BJSM the premier clinically-relevant original data journal and online community. BJSM is one of the ‘specialist journals’ of the BMJ publishing group. The mother ship – the BMJ – aims to ‘help doctors make better decisions’.

BMJ editors ask 3 questions about manuscripts that are submitted:

  1. Is it new?
  2. Is it true?
  3. Will it change what doctors do?

Given the expertise, resources, and brand recognition of the BMJ, it seems that team BJSM might do well to follow that game plan in the first instance. Thus, we will focus on clnically-relevant health and human performance.We’ll aim to accept and solicit material that is new, true, and has the potential to change the things you do.

We hope this Blog helps us engage a global community to find answers.

Exciting times!

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