FIFA Pre Competition Medical Assessment (PCMA) with additional assessment components. What is the likelihood of determining lower limb injuries among soccer players?
Nanyang Polytechnic
Physiotherapy
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PCMA assessment components.
1. FIFA Pre Competition Medical Assessment (PCMA) with additional assessment components. What is the likelihood of determining lower limb injuries among soccer players? Lin Lie Cong, Alex 085493A Qamaruzaman Bin Syed Gani 084177M Jeremy Lim 086423P Patricia Koh 084176S Valerie Yeong 085584G Fasehah Kamsin 084180U FIFA Pre-Comp. Medical Assessment. Able to detect likelihood of injury?
7. Ensure players are physically fit for play Detect risk of injury Early intervention to prevent injuries Purpose of Pre-Screening
8. Profile & History Musculoskeletal System Cardiovascular System General Physical Examination PCMA PCMA Form
9. Range of Motion (ROM) Examination of Lower Limbs Special Tests Muscle Length Musculoskeletal System
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11. Additional Assessment Components Match Hours Training Hours Hx of LL Injuries Hip Add to Abd Strength Ratio Biering Sorenson’s Active Knee Extension Dorsiflexion Lunge Test Single Leg Balance
12. Adductors 1 st 2 nd Right N N Painful No Yes Left N N Painful No Yes Abductors 1 st 2 nd Right N N Painful No Yes Left N N Painful No Yes Example of Assessment Component Adductors Right Normal Shortened Painful: No Yes Left Normal Shortened Painful: No Yes
13. To explore the use of FIFA Pre Competition Medical Assessment (PCMA) and addition of new assessment components to determine the likelihood of lower limb injuries among NYP soccer players. Aim of Study
17. TYPES OF MUSCULOSKELETAL INJURIES TRAINING MATCH LOW BACK PAIN 1 1 ADDUCTOR STRAIN - 3 HAMSTRING STRAIN - 1 ANKLE SPRAIN 1 4
18. PCMA Component % likelihood of incurring a lower limb injury % likelihood of not incurring a lower limb injury Chi Square Value P Value Ankle Anterior Drawer Sign 28.57 36.36 0.117 0.732 Additional Components Component % likelihood of incurring a lower limb injury % likelihood of not incurring a lower limb injury Chi Square Value P Value Training Hours > 24 Hours 71.43 36.36 2.104 0.147 Match Hours > 8 Hours 71.43 36.36 2.104 0.147 Single Leg Balance 28.57 36.36 0.117 0.732
19. Hip Adduction to Abduction Strength Ratio and Hip Adductor Strain Injuries Component Odds Ratio Chi Square Value P Value Hip Adductor Strength : Abductor Strength Ratio < 0.80 5.33 2.011 0.156
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24. Dr Bala Rajaratnam Project Manager (SHS- Allied Health) Mr Shiek Abdullah Project Supervisor (SHS- Allied Heath) Ms Chia Choon Yee Statistics Advisor (SHS- Allied Health) Mr Patrick Tan NYP Men & Women Soccer Team
25. Ensure players are physically fit for play Detect risk of injury Early intervention to prevent injuries Purpose of Pre-Screening
Notas do Editor
Good morning, lecturers and fellow physiotherapy students. Thank you for taking time to attend our presentation. My name is Qamaruzaman and the other members of my group are as shown. Also, if you like to find out more details on our project, please join our facebook group. The title for our final year project is as shown; FIFA Pre Competition Medical Assessment also known as PCMA with additional assessment components What is the likelihood of determining lower limb injuries among soccer players. (CLICK)
This presentation will be divided into 2 parts; where I will be covering the introduction up to the flow chart of our methodology. Alex will then take over to cover the results, limitations and lastly the conclusion. Without further ado, lets get on to the interesting part. (CLICK)
I’m sure most of you here recognise the faces as well as the logo’s shown in this pictures. According to a study done in 2006 called FIFA Big Count (CLICK), football is one of the most popular sports worldwide, with a reported 265mil or 4% of the world population involved in the game. (CLICK)
However, football, being a team and contact sports, often poses increased risk of injuries as illustrated in the above cartoon. (CLICK) A medical report from the 2006 World Cup by Dvorak et al noted that 145 injuries were reported for the 64 matches of the 2006 FIFA World Cup Germany (CLICK) —an overall injury rate of 68.7 per 1000 match hours. This is equivalent to 2.3 injuries per match. (CLICK)
The same medical report also noted that the most common locations of injury were, as expected, the ankle (18%) (CLICK), the lower leg (17%) (CLICK) and the thigh (14%) (CLICK) . Thus as shown from the pie chart, the lower limb has a higher percentage of getting injuries. (CLICK)
ManCity fans may remember Marc-Vivien Foe, a popular midfielder who collapsed and died aged 28 during a match on June 26, 2003. (CLICK) Sometimes, even the worst of tragedies can serve as a catalyst for progress. In a pioneering initiative of a sports governing body, F-MARC developed a football-specific pre-competition medical assessment (PCMA) for use in the 2006 FIFA World Cup Germany (CLICK)
So why the need for pre-screening? (CLICK) A tool to ensure that players are physically fit for play (CLICK) Also acts as a tool to detect/ identify players with a higher risk of injury (CLICK) Hence, if the tool is effective, it encourages the role of physiotherapy in preventing injuries by early intervention instead of rehabilitation only after a player is injured (CLICK)
PCMA is divided into four sections, however the Musculoskeletal system (CLICK) was the main emphasis of our project and I will be covering it in more detail in the subsequent slides. (CLICK)
As shown; the musculoskeletal system is subdivided into the following; Firstly, examination of the lower limbs Range Of Motion Muscle Length Special Tests (CLICK)
Currently there have been minimal studies done to evaluate or validate the use of PCMA in detecting likelihood of lower limb injuries. Study by Dvorak et al, 2009 in regards to the development and implementation of the PCMA at the 2006 FIFA World Cup reported that a standardized approach was possible. However results and quality of data required adaptations of the form and review of the implementation procedure. (CLICK) PCMA uses mostly qualitative measurements. For example, Valgus Stress test, divided in normal, + (low grade instability), ++ (high grade instability, clunk), +++ (high grade instability, obvious jerk) inter-rater reliability may be questioned in this case. (CLICK)
Therefore we decided to add additional components which are quantifiable as shown in the above slide. Lets take a look at how hip adductor to abductor strength ratio is documented as compared to the PCMA form
Shown above, is one of the components from PCMA. Hip adductor muscle length is identified as normal or shortened in this case. (CLICK) On the other hand, the additional component such as hip adductor and abductor strength was measured via use of a handheld dynamometer. (CLICK) Tyler et, 2001 reported that if Adductor strength < 80% of the abductor strength he/she is likely to incur adductor strain. (CLICK)
Thus, the aim of our study is to explore the use of the FIFA Pre Competition Medical Assessment and addition of new assessment components to determine the likelihood of lower limb injuries among NYP soccer players. (CLICK)
As seen from the flow chart, 18 players were recruited from Nanyang Polytechnic Soccer team. (CLICK) Inclusion Criteria - Male/Female currently and actively representing NYP Soccer Team Exclusion Criteria - Pain caused by specific disease process or injury to specific anatomic structure (CLICK) After which, we conducted the assessment prior to the POLY ITE soccer competition (also know as POLITE). Assessment was split into 2 days and 32 components from the PCMA plus the 8 additional components were used. (CLICK ON BOTTOM LEFT BOX TO SHOW LOGBOOK PIC) Players were then instructed on how and when to record down their injuries in their personal log book. (CLICK ON LOGBOOK PICTURE) (CLICK) We also monitored the players injury occurrence by attending their training twice a week as well as attending their matches at Republic Polytechnic. (CLICK) At the end of the season, we collected the log books which comprises of the injury report as well as exposure report forms. (CLICK) Once all information was collated, we begun statistical analysis with respect to lower limb injuries as per our study of determining the probability of lower limb injuries via the use of FIFA PCMA and additional new components. With that, I will pass on to Alex who will cover the results that we have gathered. (CLICK)
Hi, my name is alex and I will be bringing you through the results, discussion, limitations and the conclusion [click to go next slide]
For injuries, 7 soccer players sustained a total of 11 injuries, namely, low back pain, adductor strain, hamstring strain and ankle sprain. There is also an equal proportion of trauma and overuse injuries [click to go next slide]
This is the simplified results that we derived from our study. On the left is the component, followed by % likelihood of incurring a lower limb injury, then the % likelihood of not incurring a lower limb injury. Followed by the chi square value and P value. First the table of PCMA. From our study, if a player is deemed to be abnormal in the ankle anterior sign, the player has a 28.57% likelihood of incurring a lower limb injury while also a 36.36% likelihood of not incurring any lower limb injury. These results actually contradict each other as the player has similar chances of getting or not getting a lower limb injury. This may be due to the fact that these values are not statistically significant. This result is just one of the 32 components of the PCMA and the other 31 components displayed similar findings and are not displayed here. All in all, through our study we found that the PCMA is unable to determine the likelihood of lower limb injuries in soccer players. [click to show additional components, single leg balance only] Next is the table of additional components. From our study, if a player is deemed to be positive in the single leg balance test, the player has a 28.57% likelihood of incurring a lower limb injury while also a 36.36% likelihood of not incurring any lower limb injury. These results once again contradict each other as the player again has similar chances of getting or not getting an injury. This may be due to the fact that these values are not statistically significant as well. The other additional assessment components, such as the sorensen test, also displayed similar findings and are not displayed here. As such, through our study, we found that the additional assessment components are also unable to determine the likelihood of lower limb injuries in soccer players. [click to show match and training hours] However, lets look at training hours and match hours. From our study, if a player is has a training hours > 24 hours or match hours > 8 hours, the player has a 71.43% likelihood of incurring a lower limb injury and only 36.36% likelihood of not incurring a lower limb injury. This means that the player has almost twice the chance of incurring a lower limb injury! Although this component is still not statistically significant, it does show an association between training hours and match hours with the likelihood of lower limb injury [click to show both tables] All in all, through our study, we found that both PCMA and the additional components are unable to determine the likelihood of soccer players sustaining a lower limb injury [Click to go next slide]
As mentioned previously, there was no significant association between the PCMA components and additional components with lower limb injuries. Subsequently, we decided to analyze the additional assessment components with the specific lower limb injuries. As illustrated by qamal, this is the results showing the association between a hip adduction to abduction strength ratio with hip adductor strain injuries. If a player has a ratio of <0.80, the player has a 5.33times the odds of getting a hip adductor strain injury. Although not statistically significant, there seems to be a certain degree of association between the hip strength ratio with hip adductor strain injuries. The rest of the additional assessment components also did not show any significant association with the specific lower limb injuries. Thus the additional assessment components are also unable to determine the likelihood of specific lower limb injuries in soccer players. [click to go next slide]
[click to show first point] Through our 5 months explorative study, we found that PCMA and the additional components are unable to determine the likelihood of lower limb injuries in soccer players. However, we are unable to generalize our results to the general population or compare it with other studies due to the limitations that we have. [click to show next point]. If the PCMA is unable to determine the likelihood of lower limb injuries in soccer players, can it be that PCMA is more suited towards other purposes? Let us review the 3 purposes of pre screening as shown previously by qamal [click 2 nd point to go back to slides with 3 purpose of prescreening]. Above are the 3 purposes as mentioend previously [click to make risk of injuries disappear]. Thus, if PCMA is unable to detect the risk of injuries, can it be that it is more useful to determine if a player is fit to play through the use of comprehensive cardiovascular assessment? Or can it be that it is more useful in detecting abnormalities in players with the purpose of injury prevention? [click 3 rd box to return to discussion slide] As mentioned previously, the commonly used additional components are also unable to determine the likelihood of both lower limb injuries and specific lower limb injuries in soccer players. As compared to other tests such as the AKE, sorensen test and lunge test, only the hip strength ratio seems to show a certain degree of association with specific lower limb injury. [click to show strength assessment related test]. Hence strength-related assessment may be more able to detect the risk of injuries, in contrast to range of motion, endurance and muscle flexibility assessments. Perhaps, more research on the use of strength-related assessment as a predictive tool for injuries should be done [click to show next point] In addition, even though not statistically significant, there appears to be an association between training hours / match hours with the likelihood of lower limb injury. This actually shows that overtraining can be a predisposing factor towards injuries. This is in agreement with the 2 studies done by Ekstrand et al in 2004 and 2008, who mentioned that the fatigue as a result of overplaying may increase the risk of injury and under performance in soccer players. In the football medicine manual published by FMARC 2005 it was mentioned that overtraining can lead to increased levels of physical and psychosocial fatigue. As such, management and prevention of overtraining may be an effective method that we physiotherapist can utilize in order to reduce risk of injuries. This in turn requires more research. [click to show next point] Finally, if PCMA and the additional components are unable to determine the likelihood of lower limb injuries in soccer players, there is definitely a need for more tools and assessment techniques that can determine the risk of a player sustaining a lower limb injury. For example, in the area of fitness, Bangsbo et al 2008 and Castagna et al 2006, both mentioned that the YO YO test is a good test to determine the aerobic fitness of a player, instead of the conventional treadmill test. So if there are good tools in the area of fitness assessment, appropriate tools to determine the risk of lower limb injuries will definitely be advantageous as well [click to show next slide]
However, our study is subjected to some limitations. [click to show first point] Firstly, all the information, e.g. the exposure hours and training hours are self reported, thus bringing question to the accuracy of the data provided by the players [click to show next point] Secondly, through our explorative 5 month study, we are unable to establish any statistical significance in our data. Subsequently we are unable to generalize our results to the general population or compare it with other studies [click to show next point] Thirdly, we are unable to control the subject’s physical activity outside of our study, and this will definitely affect whether the players sustain an injury or not [click to show next point]
For future studies [click to show first point], we can incorporate more players from our school soccer club and external soccer clubs. This increased number and variety of participants will definitely yield an even more convincing result [click to show next point] Our current study is based on an assessment form that consist of many components, and is thus very broad based. Future studies zooming in on one specific component, e.g. the knee and its associated tests, may provide a different perspective in terms of determining the likelihood of injuries [click to show next point] In addition, after our study, we conduct a post study survey to all our 18 participants. All of them felt that our study is beneficial and some felt that the addition of an intervention will be even better. This shows that for future studies, application of intervention may also be a possible route [click to show next point] Finally, as mentioned previously, research on more tools in predicting risk of injuries in soccer players is definitely required [click to show next point]
In conclusion [click to show first point], Through our study, we found that PCMA and additional assessment components are unable to determine the likelihood of lower limb injuries [click to show next point] If PCMA is unable to determine the likelihood of injuries, the PCMA might be more useful in other purposes such as abnormalities detection for injury prevention and to determine if a player is fit to play [click to go next point] Thirdly, we also found that lower limb injuries are associated with training and match hours, although not statistically significant [click to show next point] In addition, through our study, it is interesting that strength assessment may be a useful tool to predict the risk of injuries, as illustrated previous using the hip adductor strength ratio. However this in turn requires more research [click to go next point] Finally, there is definitely a need for more tools to predict the risk of lower limb injuries. Future studies are definitely required to confirm our findings as well [click to go next slide]
Finally, we would like to thank the following people for their kind help. Our project wouldn’t have been possible without them. This is the end of our presentation, thank you [stop here don’t click anymore]
So why the need for pre-screening? (CLICK) A tool to ensure that players are physically fit for play (CLICK) Also acts as a tool to detect/ identify players with a higher risk of injury (CLICK) Hence, if the tool is effective, it encourages the role of physiotherapy in preventing injuries by early intervention instead of rehabilitation only after a player is injured (CLICK)
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