Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-015-3636-2
SPORTS MEDICINE
Professional football can be considered a healthy sport? Gustavo Gonçalves Arliani1 · Diego Costa Astur1 · Ricardo Kim Fukunishi Yamada2 · Andre Fukunishi Yamada3 · Artur da Rocha Corrêa Fernandes3 · Benno Ejnisman1 · Alberto de Castro Pochini1 · Moises Cohen1
Received: 9 October 2014 / Accepted: 4 May 2015 © European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2015
Abstract Purpose This study aimed to compare the results of knee MRIs of former football players with no previous knee surgeries with non-regular practitioners of impact sports, matched by age and sex, and combine these results with other variables such as current quality of life and pain in the knees. Methods The study participants were 16 male former professional football players and 21 male volunteers from different non-sports professional areas. All participants underwent bilateral magnetic resonances. Specific knee evaluations with regard to osteoarthritis and quality of life were performed in both groups by applying the Knee Injury and Osteoarthritis Outcome Score (KOOS) subjective questionnaires and SF-36, respectively. Results The between-group comparison revealed significant differences on: pain, symptoms, and quality of life related to the knee in KOOS subscales; physical aspects and vitality subscale of SF-36; and former soccer players had worst magnetic resonances scores than controls.
* Gustavo Gonçalves Arliani [email protected] 1
Departamento de Ortopedia e Traumatologia, Centro de Traumatologia do Esporte (CETE), Universidade Federal de São Paulo (DOT-UNIFESP/EPM), Rua Borges Lagoa, 783, 5° andar, Vila Clementino, São Paulo, SP CEP 04038‑032, Brazil
2
Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo (DOT-UNIFESP/EPM), São Paulo, SP, Brazil
3
Departamento de Diagnóstico por Imagem, Universidade Federal de São Paulo (UNIFESP/EPM), São Paulo, SP, Brazil
Conclusion Results of this study indicate probable specific adverse effects associated with participating in professional football. Level of evidence Cross-sectional study, Level III. Keywords Osteoarthritis · Knee · Soccer · Football · MRI · Retirement
Introduction Football is undoubtedly the most popular sport in the world. Approximately 200,000 professional and 240 million amateur football athletes, of which approximately 80 % are male, play around the world. Currently, participation in sports is seen as favourable to healthy development. As a sport, football has undergone many changes over recent years, primarily due to the increasing physical demands that force athletes to work close to their maximum capacity, predisposing them to overloaded joints [8, 9]. In football, the most common injuries affect the lower limbs (70–80 %) with the majority involving the knees and ankles. The gold standard image tool on the evaluation of knee injuries is the magnetic resonance image (MRI), which has been shown to be an accurate method in the diagnosis of sports-related injuries such as bone bruises, joint effusion, cartilage, ligaments, meniscus, and tendon injuries [2, 17]. In accordance with a previous study with National Basketball Association (NBA) players driven by Walczak et al. [16], magnetic resonance imaging of the knee may be clinically useful to prevent injuries and improve diagnostic accuracy. Therefore, MRI can be a useful and innovative technique for early detection of osteoarticular lesions in the knees of football players.
13
This study compared the results of knee MRIs of former football players with no previous knee surgeries with non-regular practitioners of impact sports, matched by age and gender, and combined these results with other variables such as current quality of life and pain in the knees. It is extremely important to define and discuss the correlations between football participation and negative effects so that plans to solve or reduce problems can be developed.
Materials and methods Participants This controlled, cross-sectional study was conducted between January 2011 and January 2013. The study participants were 16 former professional football players and 21 volunteers from different non-sports professional areas. All participants were male. The former athletes were recruited from a group of 32 former professional football players. This sample consisted of all former athletes of an association of former football players who met the inclusion criteria. From this total sample, sixteen former players were not part of the final sample. This is because three were currently living in other distant regions, two declined to participate in the study, and eleven were submitted to previously knee surgeries. The 21 volunteers were recruited from the various sectors of a university campus. These professionals had different occupations and were matched with the former players by gender and age. At most, they would have played football and other sports recreationally. Inclusion and exclusion criteria Former players group Former male professional football players were included in the study who had played first division football, were aged between 30 and 55 years at the time of study, whose professional career had lasted at least 5 years, and who had participated in training and matches during this period. Individuals with congenital diseases associated with knee deformity, prior histories of lower limb fractures, histories of inflammatory, metabolic, or infectious arthropathy in one or both knees, hip, or knee arthroplasty in one or both knees, any contraindication to MRI, acute orthopaedic lesions (last 3 months), or any previous knee surgery were excluded from both groups.
13
Knee Surg Sports Traumatol Arthrosc
Control group The control group was composed of individuals who were matched with the former players. They were matched by gender and age. Evaluation To characterize the clinical sample, the following variables were evaluated: age, current weight, weight during professional athletic career, height, body mass index (BMI), position, lower limb dominance, duration of professional career, current participation in recreational football, history of drug injections in the knee during career, and current occupation. Current bilateral knee pain was quantified with the visual analogue scale (VAS) using a ruler with 100 mm on one of its faces. After explaining that the line represented feeling with regard to pain, individuals scored the pain in their knees from 0 (no pain) to 100 mm (maximum pain). Thus, their score was recorded on a millimetre ruler from 0 to 10 to quantify the pain sensitivity of each participant [6]. Specific knee evaluations with regard to osteoarthritis and quality of life were performed by applying the Knee Injury and Osteoarthritis Outcome Score (KOOS) subjective questionnaires and SF-36, respectively [3, 4]. A blinded MRI evaluation was conducted by a radiologist with 10 years of experience in assessing musculoskeletal imaging. The radiologist used a global evaluation method for osteoarthritic knees [Whole-Organ Magnetic Resonance Imaging Score (WORMS)], which is applicable to traditional MRI examinations. This method is used to determine the direct prevalence of injury to all knee structures and quantifies the injuries using objective scores from 0 to 332 [11]. All MRI examinations were performed on a 1.5 T (Intera Gyroscan ACS-NT, Phillips). Bilateral knee MRI was done in all participants. The standardized imaging protocol included axial, coronal, and sagittal knee cuts with a T2-weighted Fast Spin-Echo (FSE) sequence with fat-suppression, proton density-weighted FSE, and T1-weighted FSE on the coronal plane. The image parameters included a 256 × 128 array, a slice thickness between 3.5 and 4.0 mm, 0.4-mm spacing, and a field of view (FOV) of 18–20 cm. The Ethics and Research Committee of Universidade Federal de São Paulo/Brazil approved this study (IRB 0629/10), and all participants signed informed consent (IC) forms.
Knee Surg Sports Traumatol Arthrosc
Results
Table 1 Baseline demographic characteristics Variable
Group
Median
SD
p
Age (years)
Control Former players Control Former players Control Former players Control
46.48 44.38 86.1 82.38 1.72 1.78 28.78
6.0 4.97 13.35 11.23 0.07 0.05 3.88
n.s.
Former players
25.96
3.58
Actual weight (kg) Height (m) BMI (kg/m2)
n.s. 0.005 0.03
Bold values indicate greater height in former players group and increased BMI in control group Table 2 Players positions during their career Position
n
%
Goalkeeper Defence Midfielder Forward
2 4 6 4
12.5 25.0 37.5 25.0
Total
16
100
Statistical analysis Quantitative variables were reported as means, medians, and standard deviations; qualitative variables were displayed as percentages and absolute frequencies. An analysis of normality (Kolmogorov–Smirnov test) was performed for all scales and quantitative variables, and as scales escape from normality assumption, Mann–Whitney test was adopted. For between-group comparisons, the Chi-square test, Fisher’s exact test, Mann–Whitney U test, and Student’s t test were used. Values were considered significant at
SPORTS MEDICINE
Professional football can be considered a healthy sport? Gustavo Gonçalves Arliani1 · Diego Costa Astur1 · Ricardo Kim Fukunishi Yamada2 · Andre Fukunishi Yamada3 · Artur da Rocha Corrêa Fernandes3 · Benno Ejnisman1 · Alberto de Castro Pochini1 · Moises Cohen1
Received: 9 October 2014 / Accepted: 4 May 2015 © European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2015
Abstract Purpose This study aimed to compare the results of knee MRIs of former football players with no previous knee surgeries with non-regular practitioners of impact sports, matched by age and sex, and combine these results with other variables such as current quality of life and pain in the knees. Methods The study participants were 16 male former professional football players and 21 male volunteers from different non-sports professional areas. All participants underwent bilateral magnetic resonances. Specific knee evaluations with regard to osteoarthritis and quality of life were performed in both groups by applying the Knee Injury and Osteoarthritis Outcome Score (KOOS) subjective questionnaires and SF-36, respectively. Results The between-group comparison revealed significant differences on: pain, symptoms, and quality of life related to the knee in KOOS subscales; physical aspects and vitality subscale of SF-36; and former soccer players had worst magnetic resonances scores than controls.
* Gustavo Gonçalves Arliani [email protected] 1
Departamento de Ortopedia e Traumatologia, Centro de Traumatologia do Esporte (CETE), Universidade Federal de São Paulo (DOT-UNIFESP/EPM), Rua Borges Lagoa, 783, 5° andar, Vila Clementino, São Paulo, SP CEP 04038‑032, Brazil
2
Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo (DOT-UNIFESP/EPM), São Paulo, SP, Brazil
3
Departamento de Diagnóstico por Imagem, Universidade Federal de São Paulo (UNIFESP/EPM), São Paulo, SP, Brazil
Conclusion Results of this study indicate probable specific adverse effects associated with participating in professional football. Level of evidence Cross-sectional study, Level III. Keywords Osteoarthritis · Knee · Soccer · Football · MRI · Retirement
Introduction Football is undoubtedly the most popular sport in the world. Approximately 200,000 professional and 240 million amateur football athletes, of which approximately 80 % are male, play around the world. Currently, participation in sports is seen as favourable to healthy development. As a sport, football has undergone many changes over recent years, primarily due to the increasing physical demands that force athletes to work close to their maximum capacity, predisposing them to overloaded joints [8, 9]. In football, the most common injuries affect the lower limbs (70–80 %) with the majority involving the knees and ankles. The gold standard image tool on the evaluation of knee injuries is the magnetic resonance image (MRI), which has been shown to be an accurate method in the diagnosis of sports-related injuries such as bone bruises, joint effusion, cartilage, ligaments, meniscus, and tendon injuries [2, 17]. In accordance with a previous study with National Basketball Association (NBA) players driven by Walczak et al. [16], magnetic resonance imaging of the knee may be clinically useful to prevent injuries and improve diagnostic accuracy. Therefore, MRI can be a useful and innovative technique for early detection of osteoarticular lesions in the knees of football players.
13
This study compared the results of knee MRIs of former football players with no previous knee surgeries with non-regular practitioners of impact sports, matched by age and gender, and combined these results with other variables such as current quality of life and pain in the knees. It is extremely important to define and discuss the correlations between football participation and negative effects so that plans to solve or reduce problems can be developed.
Materials and methods Participants This controlled, cross-sectional study was conducted between January 2011 and January 2013. The study participants were 16 former professional football players and 21 volunteers from different non-sports professional areas. All participants were male. The former athletes were recruited from a group of 32 former professional football players. This sample consisted of all former athletes of an association of former football players who met the inclusion criteria. From this total sample, sixteen former players were not part of the final sample. This is because three were currently living in other distant regions, two declined to participate in the study, and eleven were submitted to previously knee surgeries. The 21 volunteers were recruited from the various sectors of a university campus. These professionals had different occupations and were matched with the former players by gender and age. At most, they would have played football and other sports recreationally. Inclusion and exclusion criteria Former players group Former male professional football players were included in the study who had played first division football, were aged between 30 and 55 years at the time of study, whose professional career had lasted at least 5 years, and who had participated in training and matches during this period. Individuals with congenital diseases associated with knee deformity, prior histories of lower limb fractures, histories of inflammatory, metabolic, or infectious arthropathy in one or both knees, hip, or knee arthroplasty in one or both knees, any contraindication to MRI, acute orthopaedic lesions (last 3 months), or any previous knee surgery were excluded from both groups.
13
Knee Surg Sports Traumatol Arthrosc
Control group The control group was composed of individuals who were matched with the former players. They were matched by gender and age. Evaluation To characterize the clinical sample, the following variables were evaluated: age, current weight, weight during professional athletic career, height, body mass index (BMI), position, lower limb dominance, duration of professional career, current participation in recreational football, history of drug injections in the knee during career, and current occupation. Current bilateral knee pain was quantified with the visual analogue scale (VAS) using a ruler with 100 mm on one of its faces. After explaining that the line represented feeling with regard to pain, individuals scored the pain in their knees from 0 (no pain) to 100 mm (maximum pain). Thus, their score was recorded on a millimetre ruler from 0 to 10 to quantify the pain sensitivity of each participant [6]. Specific knee evaluations with regard to osteoarthritis and quality of life were performed by applying the Knee Injury and Osteoarthritis Outcome Score (KOOS) subjective questionnaires and SF-36, respectively [3, 4]. A blinded MRI evaluation was conducted by a radiologist with 10 years of experience in assessing musculoskeletal imaging. The radiologist used a global evaluation method for osteoarthritic knees [Whole-Organ Magnetic Resonance Imaging Score (WORMS)], which is applicable to traditional MRI examinations. This method is used to determine the direct prevalence of injury to all knee structures and quantifies the injuries using objective scores from 0 to 332 [11]. All MRI examinations were performed on a 1.5 T (Intera Gyroscan ACS-NT, Phillips). Bilateral knee MRI was done in all participants. The standardized imaging protocol included axial, coronal, and sagittal knee cuts with a T2-weighted Fast Spin-Echo (FSE) sequence with fat-suppression, proton density-weighted FSE, and T1-weighted FSE on the coronal plane. The image parameters included a 256 × 128 array, a slice thickness between 3.5 and 4.0 mm, 0.4-mm spacing, and a field of view (FOV) of 18–20 cm. The Ethics and Research Committee of Universidade Federal de São Paulo/Brazil approved this study (IRB 0629/10), and all participants signed informed consent (IC) forms.
Knee Surg Sports Traumatol Arthrosc
Results
Table 1 Baseline demographic characteristics Variable
Group
Median
SD
p
Age (years)
Control Former players Control Former players Control Former players Control
46.48 44.38 86.1 82.38 1.72 1.78 28.78
6.0 4.97 13.35 11.23 0.07 0.05 3.88
n.s.
Former players
25.96
3.58
Actual weight (kg) Height (m) BMI (kg/m2)
n.s. 0.005 0.03
Bold values indicate greater height in former players group and increased BMI in control group Table 2 Players positions during their career Position
n
%
Goalkeeper Defence Midfielder Forward
2 4 6 4
12.5 25.0 37.5 25.0
Total
16
100
Statistical analysis Quantitative variables were reported as means, medians, and standard deviations; qualitative variables were displayed as percentages and absolute frequencies. An analysis of normality (Kolmogorov–Smirnov test) was performed for all scales and quantitative variables, and as scales escape from normality assumption, Mann–Whitney test was adopted. For between-group comparisons, the Chi-square test, Fisher’s exact test, Mann–Whitney U test, and Student’s t test were used. Values were considered significant at
