Keywords player welfare - athlete health - long-term athlete care
Introduction
There is an increasing awareness in professional sport of the need to provide medical
after-care to retired athletes.[1 ]
[2 ]
[3 ] These initiatives stem from a recognition that although professional
sport brings significant health benefits, some retired athletes may face specific
health challenges related to their sporting career.[4 ] In professional football, there is
established evidence that retired players are at increased risk of musculoskeletal
health issues in later life and that they may be more prone to mental health
symptoms during the transition to retirement.[5 ]
[6 ] Common musculoskeletal
health issues among retired professional footballers include early-onset
osteoarthritis (OA), which is often associated with a history of severe injury
and/or surgery during their playing career.[5 ]
[7 ] This, along with life
events and lack of social support, may have a negative effect on the quality of life
and/or mental health of retired professional footballers.[8 ]
[9 ]
[10 ] Additionally, there
are emerging concerns that there may be an increased risk of neurocognitive
conditions such as dementia among retired professional footballers.[11 ]
[12 ]
[13 ]
[14 ] This potentially increased risk is
thought to relate to the effects of concussion and/or repetitive sub-concussive
impacts (e.g., heading) on long-term neurological health, although more research is
required to establish causal inference.[11 ]
In 2018, an After-Career Consultation (ACC) was developed to empower the physical,
mental and social health of retired professional footballers and effectively address
some of their specific health challenges.[15 ] The ACC focussed on five health-related domains thought to be most
relevant for retired players, namely detraining from professional football;
management of OA; promotion of a healthy lifestyle; preventing mental and cognitive
health problems; and employment and education. This intervention was well received
by the retired professional footballers partaking in a pilot study.[15 ] Therefore, Fédération Internationale
de Football Association (FIFA) and Fédération Internationale des Associations de
Footballeurs Professionnels (FIFPRO) agreed to collaborate from 2020 to provide
retired male professional footballers worldwide with the ACC.[16 ] The primary objective of this study
was to describe the clinical outcomes (e.g., prevalence of health conditions,
associations with contributing factors) and recommendations to retired male
professional footballers who undertook the ACC. A secondary objective was to record
the investigations and onward referrals arranged as a result of the ACC. A tertiary
objective was to describe patient satisfaction and experience following the ACC.
Methods
Design
As randomisation was not practical or ethical, a quasi-experimental study based
on a one-group post-test design was conducted, using the Transparent Reporting
of Evaluations with Nonrandomized Designs (TREND) guidelines to ensure a high
quality of reporting.[17 ]
[18 ] Ethical approval for the study
was provided by the Medical Ethics Review Committee of the Amsterdam University
Medical Centers, location University of Amsterdam (W21_135 # 21.150; Amsterdam,
The Netherlands). The study was conducted in accordance with the principles set
out in the Declaration of Helsinki (2013).[19 ]
Participants
Between April 2021 and June 2023, a convenient sample of 47 retired male
professional footballers underwent ACCs at FIFA Medical Centres (or a suitable
equivalent) across six different countries. The inclusion criteria were: (i)
male sex; (ii) retired professional footballer; (iii) ability to understand and
speak English; and (iv) access to a clinic performing the ACC. In our study, a
retired male professional footballer was defined as an individual who was
remunerated for devoting several hours in all/most days (exceeding the time
allocated to other types of professional or leisure activities) to playing
football.[20 ] Potential
participants were informed by email and/or social media about the worldwide
implementation of the ACC and related study via FIFPRO’s national player unions
and via the individual network of the FIFA Medical Centres of Excellence.
Retired players participated voluntarily in the study and did not receive any
financial remuneration for their participation.
Intervention
After giving their informed consent to partake in the study, participants
completed an online form which evaluated, among other things, playing history,
time elapsed since retirement, medical history, injury (and surgical) history,
mental health symptoms and lifestyle factors. Upon completing the online form,
the participants were invited by the FIFA Medical Centre of Excellence (or
another suitable clinic) to undergo the ACC (60-min duration) at a convenient
time by a suitably qualified physician. The ACC was individualised to each
participant (based on their responses on the online form), but generally
included an emphasis on musculoskeletal, mental, neurocognitive and
cardiovascular health. Based on all information gathered through the ACC
(self-reported and clinical findings), tailored recommendations (e.g., advice,
intervention, further investigation, secondary referral) were made to the
participants. A flowchart detailing the patient journey for participants is
outlined in [Fig. 1 ]. The
information, registration, online, consultation and recommendation forms are
available for review in the Supplementary material (available in the online
version only). Completed forms were shared with and securely stored by the
primary researcher.
Fig. 1 Flowchart detailing the patient journey for
participants.
Primary outcome measures
Our primary outcome measures were related to the health conditions (and related
recommendations) which have been identified as a concern among retired male
professional footballers, related especially to the musculoskeletal health,
mental health, neurocognitive health and cardiovascular health domains.[5 ] The specific measurements for each
domain are presented below.
Musculoskeletal health
The number of severe musculoskeletal injuries in the player’s career was
recorded. A severe injury was defined as ‘an injury that occurred during
team activities and led to either training or match absence for more than 28
days (4 wks)’.[21 ]
[22 ] The number of surgeries
required as a result of an injury sustained during a footballer’s career was
assessed by a single question; ‘How many surgeries as a consequence of an
injury have you had during your professional football career?’. Clinical OA
was assessed according to the definition provided by the National Institute
for Health and Care Excellence, with the diagnostic criteria including: (i)
the presence of activity-related joint pain, (ii) restricted range of motion
and (iii) either no morning joint-related stiffness or morning stiffness
that lasts no longer than 30 minutes.[23 ]
Mental health
Anxiety, depression, substance misuse and sleep disturbance were the mental
health symptoms assessed during the ACC. Anxiety was assessed using the
validated Generalised Anxiety Disorder (GAD-7) questionnaire, which is used
to assess symptoms related to anxiety over the last 2 weeks (e.g., How often
have you been bothered by not being able to stop or control worrying?).[24 ] A total score ranging from 0
to 21 was calculated with higher sum scores indicating greater anxiety
severity (0–4: normal; 5–9: mild; 10–14: moderate; and≥15: severe) and a sum
score of≥10 indicating symptoms consistent with a diagnosis of generalised
anxiety disorder.[20 ] The Patient
Health Questionnaire-9 was used to assess the presence of symptoms of
depression in the previous 2 wks (e.g., ‘Have you been feeling down,
depressed or hopeless?’) scored on a 4-point scale (from ‘not at all’ to
‘nearly every day’). A total sum score ranging from 0 to 27 was calculated,
with higher sum scores indicating greater depression severity (0–4: normal;
5–9: mild; 10–14: moderate; and≥15: [moderate to] severe) and a sum score
of≥10 indicating symptoms consistent with a diagnosis of depression.[25 ]
[26 ] The level of alcohol
consumption was detected using the validated three-item Alcohol Use
Disorders Identification Test (AUDIT-C; e.g., ‘How many standard drinks
containing alcohol do you have on a typical day?’). A total score ranging
from 0 to 12 was obtained by summing up the answers on the three items, with
a score of 5 or more indicating the presence of alcohol misuse.[27 ]
[28 ] Sleep disturbance was
measured using the shortened Athlete Sleep Screening Questionnaire (ASSQ),
sleep disturbance in the previous recent past was assessed through five
items (e.g., ‘How satisfied/dissatisfied are you with the quality of your
sleep?’) scored on 4-point and 5-point scales. A total score ranging from 1
to 17 was obtained by summing up the answers to the five items, with a score
of 8 or more indicating the presence of moderate sleep disturbance.[29 ]
[30 ]
Lifestyle factors
Lifestyle factors assessed smoking status, diet and exercise. Smoking status
was assessed through a single question (‘Do you smoke?’). Participants were
invited to describe their diet, with five options ranging from ‘Very
healthy’ to ‘Very unhealthy’. For exercise, participants were asked ‘In a
typical week, on how many days do you do moderate - vigorous intensity
sports, fitness or recreational (leisure) activities?’, with a free-text box
provided to enter a number.
Health-related quality of life
The Patient-Reported Outcomes Measurement Information System Global Health
(PROMIS-GH) was used to assess multiple domains related to health-related
quality of life, such as physical health, levels of function, pain, social
activities and fatigue.[31 ] Based
on 10 items, each measured on a 5-point scale (from 1 to 5) and subsequently
converted, the Global Physical Health and Global Mental Health scores were
calculated.[31 ] The Global
Physical Health score was calculated by adding the scores of items 3, 7, 9
and 10 of the quality of life questions on the questionnaire to obtain a
subscale score out of 20. The questions relate to physical health, ability
to carry out social activities and roles, fatigue and pain. The Global
Mental Health score was calculated by adding the scores of items 2, 4, 5 and
8 to obtain a subscale score out of 20. The questions relate to quality of
life, mental health, satisfaction with social activities and relationships
and being bothered by emotional problems. Higher scores indicate a better
quality of life.[31 ]
Neurocognitive health
A single question was asked related to concussion history; ‘How many
concussions have you had during your professional football career?’. A
concussion was defined as ‘a direct or transmitted blow to the head
resulting in symptoms such as headache, nausea, vomiting, dizziness/balance
problems, fatigue, trouble sleeping, drowsiness, sensitivity to light or
noise, blurred vision, difficulty remembering, and difficulty
concentrating’.[32 ]
Cardiovascular health
Cardiovascular health was assessed through screening questions (e.g., ‘Does
the player experience relevant symptoms such as chest pain, palpitations,
presyncope, syncope, shortness of breath?’), body composition (height,
weight, skinfold assessment), blood pressure (BP), resting heart rate and a
standard 12-lead electrocardiogram (ECG). BP was interpreted according to
internationally accepted criteria (e.g.,≥140/90 mmHg indicates
hypertension).[33 ] ECG
abnormalities were defined according to the international criteria for
electrocardiographic interpretation in athletes.[34 ]
Clinical recommendations
Specific clinical recommendations were made to each player, dependent on the
findings of the preceding assessment. In addition to the key medical domains
highlighted above, the recommendations related to ‘lifestyle’ and ‘other’
are provided. If recommendations were made related to these domains, the
physician completing the ACC was invited to highlight the degree of
significance of these recommendations (e.g., slightly significant,
significant, very significant). A free-text box was provided for the
physician to elaborate on the recommendations they made based on the
outcomes of the ACC.
Secondary outcome measures
Our secondary outcome measures included the arrangement of further investigations
and secondary referral based on the clinical findings of the ACC. These were
assessed based on single questions (e.g., ‘Based on your assessment, do you plan
to arrange any further investigation(s) for the retired footballer?’ and ‘Do you
plan to arrange secondary referral for the retired footballer?’).
Tertiary outcome measures
All players who underwent an ACC were contacted by email to complete a short
(six-item) electronic survey evaluating their satisfaction and experience of the
ACC. The survey included questions, such as ‘What is the primary reason(s) you
choose to go to the After-Career Consultation?’, and statements, such as ‘Please
indicate to what extent you agree with the following: I would recommend the
After-Career Consultation to my (former) teammates with a health concern’ and
‘Do you have any suggestions to improve/alter the After-Career Consultation?’.
Questions were answered on different response scales (e.g., ‘yes, no’ or
free-text), while statements were scored on a 5-point Likert scale from
‘strongly disagree’ to ‘strongly agree’. The survey is available for review in
the Supplementary material (available in the online version only).
Descriptive variables
In addition to the outcomes stated above, the following descriptive variables
were assessed: (family) history of cardiovascular disease, diabetes mellitus,
medication use, employment status (post-retirement), professional football
exposure (single questions about number of seasons and matches played), level of
play, and educational level.
Data analysis
All data analyses were conducted by using the statistical software IBM SPSS
Statistics (Version 28.01.0).[35 ]
Descriptive analyses (mean, standard deviation, frequency, and range) were
performed for all variables included in the study. For our primary objective,
prevalence was calculated for all health conditions. Prevalence (expressed as a
percentage) was calculated as the proportion of the number of participants with
a given health condition relative to the total number of participants. Potential
associations between contributing factors and independent variables were
assessed using Spearman’s rank correlation coefficient.[36 ] For our secondary and tertiary
objectives, we used descriptive analyses (mean, standard deviation, frequency,
and/or range) to evaluate the investigations and onward referrals arranged as a
result of the ACC and present the participants’ satisfaction and experience of
undergoing the ACC.
Results
Participant characteristics
Forty-seven retired male professional footballers underwent the ACC and were
included for final analysis. The mean age of participants was 38.1 years
(SD=5.4). The mean height and weight were 181.0 cm and 84.4 kg, respectively.
The average duration of retirement at the time of the ACC was 5.5 years
(SD=3.0). Twelve (25.5%) participants were from North America (CONCACAF) and 35
(74.5%) were from Europe (UEFA). The average number of seasons as a professional
footballer was 15.8 years (SD=5.4). The majority (n =43, 91.5%) reported
primarily having played at the highest national level/league. Participants had
played 390 games on average in their professional football career. Forty-two
(89.4%) of the participants were in paid employment at the time of their ACC.
Full participant characteristics are presented in [Table 1 ].
Table 1 Participant characteristics (n =47)
Current age (yr)
38.1 mean, 5.4 SD, range 27–53
Height (cm)
181.0 mean, range 167.0–190.0
Weight (kg)
84.4, range 69.0–113.0
Nationality
Italy
n =5, 10.6%
Malta
n =10, 21.3%
Mexico
n =10, 21.3%
Republic of Ireland
n =10, 21.3%
Spain
n =1, 2.1%
United Kingdom
n =9, 19.2%
USA
n =2, 4.3%
Currently in employment
Yes
n =42, 89.4%
Number of years since retirement
5.47 (SD=3.0)
Number of seasons as a professional footballer
15.8 mean, range 1–30
Estimated no. of matches as a professional footballer
390 mean, range 2–1040
Played in the highest national league
n =43, 91.5%
Position (more than one option available for selection)
Goalkeeper
n =7, 14.9%
Full back
n =7, 14.9%
Central defender
n =8, 17%
Defensive midfielder
n =6, 12.8%
Attacking midfielder
n =10, 21.3%
Winger
n =5, 10.6%
Striker
n =5, 10.6%
Clinical outcomes and recommendations
Medical history
Eight of the participants (17%) reported a recent hospital admission for
elective procedures (e.g., total hip replacement) or acute admission (e.g.,
renal colic, spontaneous pneumothorax). Five of the participants (10.6%)
used regular medications (e.g., insulin, ADHD medication, asthma inhaler,
PPI), with only one participant reporting regular use of non-steroidal
anti-inflammatory medications. Five of the participants (10.6%) reported
that they had been diagnosed with a condition relevant to their future
health: including diabetes (n =2), pericardial cyst, myocarditis, and
psoriatic arthritis.
Musculoskeletal health
A breakdown of the participants’ musculoskeletal health can be found in [Table 2 ]. The average number of
severe injuries (>4-wk time loss) sustained during their playing career
was 3 per player (range 0–15). The average number of surgeries related to
injuries sustained during their professional career was 2 per player (range
0–5). The prevalence of clinical OA (according to pre-defined criteria)[23 ] was 21.3% (n =10). The
average age of the participants with evidence of clinical OA was 39.1 yrs
(range 34–53). The distribution of clinical OA in these 10 participants is
shown in [Fig. 2 ].
Fig. 2 The distribution of osteoarthritis (OA) among
participants.
Table 2 Medical conditions (n =47)
Musculoskeletal health (n =46)
No. of severe injuries
3.2 mean, SD=3.4 (range 0–15)
No. of surgeries
1.6 mean, SD=1.6 (range 0–5)
Mental health of participants (n =47)
GAD-7
4.3 mean (SD=4.2)
PHQ-9
4.0 mean (SD=5.0)
AUDIT-C
3.5 mean (SD=1.9)
Lifestyle factors (n =47)
ASSQ
5.4 mean (SD=2.6)
Smoker
n =2, 4.3%
Health-related quality of life
Global Physical Health score mean
39.8
Global Mental Health score mean
41.7
Neurocognitive health (n =45)
No. of participants who had been diagnosed with a
concussion
n =13
Mean no. of concussions per participant
0.4
Mean no. of concussions per participant diagnosed with a
concussion
2 (range 1–4)
Cardiovascular health (n =46)
Abnormal ECG findings
n =5, 10.9%
GAD-7, General Anxiety Disorder 7 (0–4: normal; 5–9: mild; 10–14:
moderate; and≥15: severe); PHQ-9, Patient Health Questionnaire-9
(0–4: normal; 5–9: mild; 10–14: moderate; and≥15: [moderate to]
severe); AUDIT-C, alcohol use disorders identification test
consumption (a score of 5 or more indicating the presence of alcohol
misuse); ASSQ, Athlete Sleep Screening Questionnaire (a score of 8
or more indicating the presence of moderate sleep disturbance); ECG,
electrocardiogram.
Mental health
The 2-wk prevalence of symptoms consistent with a diagnosis of generalised
anxiety disorder was 8.5% (n =4), with 29.8% (n =14) meeting
criteria for mild anxiety. The 2-wk prevalence of symptoms consistent with a
diagnosis of depression was 14.9% (n =7), including two individuals
with moderate–severe depression. Five participants (10.6%) showed evidence
of mild depression. Nearly a quarter (n =11) misused alcohol. Five
participants (10.6%) had evidence of moderate sleep disturbance, with two
(4.3%) meeting the criteria for severe sleep disturbance. Data on the mental
health of the participants are presented in [Table 2 ].
Lifestyle factors
Two of the participants were smokers (4.3%). Over half (n =25) of the
participants reported their diet to be either ‘very healthy’ (n =7,
14.9%) or ‘healthy’ (n =18, 38.3%). In total, participants reported
engaging in moderate to vigorous exercise (e.g., sports, recreational
activities, fitness) on 3 days per week on average. Data on lifestyle
factors of the participants are presented in [Table 2 ].
Health-related quality of life
The mean Global Physical Health score among retired professional footballers
was 51.9. The mean Global Mental Health score among retired professional
footballers was 51.7 (see [Table
2 ]).
Neurocognitive health
Thirteen (27.7%) of the participants reported being diagnosed with a
concussion during their career. For those who had been diagnosed with a
concussion, the average was 2 concussions per player (range 1–4) (see [Table 2 ]).
Cardiovascular health
Seven participants (14.9%) met the criteria for Stage 1 hypertension; namely,
a clinic BP reading ranging from 140/90 to 159/99 mmHg.[37 ] Forty-six participants
underwent a 12-lead ECG, from which five participants (10.9%) had an
abnormal ECG finding according to pre-defined criteria.[34 ] Abnormal ECG findings among
these five participants included anterior (n =2) and inferior t-wave
inversion (n =1), features of left atrial enlargement (n =2),
and complete right bundle branch block (n =1). Data on the
cardiovascular health of the participants are presented in [Table 2 ].
Clinical recommendations
Clinical recommendations were made to 12 (25.5%) participants in relation to
their musculoskeletal health. Half of these findings/recommendations were
deemed by the clinician to be ‘significant’ (e.g., arrange magnetic
resonance imaging [MRI] of both knees, limit weight-bearing exercise) and
‘very significant’ (e.g., total hip replacement likely needed due to OA).
Clinical recommendations were made to 12 (25.5%) of participants in relation
to their cardiovascular health, with these findings/recommendations thought
to be ‘significant’ in five of the cases (e.g., annual cardiology review)
and ‘slightly significant’ in the remainder (e.g., regular BP monitoring).
Clinical recommendations were only made to one player in relation to
neurocognitive health, which was deemed to be ‘significant’ (arrange
psychiatric review in relation to a pre-existing diagnosis of ADHD and
associated sleep, mood and substance misuse issues). Ten players (21.3%)
received recommendations in relation to their mental health, with two of
these recommendations highlighted as ‘very significant’ (e.g., psychiatric
review). Twenty participants (42.6%) received lifestyle recommendations,
with nine deemed ‘slightly significant’ (e.g., maintain a healthy diet) and
8 ‘significant’ (17.0%) (e.g., reduce alcohol intake, improve sleep habits).
No additional recommendations were made to any participants who were in
health domains separate from those already described.
Investigations and referrals
Eleven of the participants (23.4%) were referred for further investigations based
on the findings from their ACC. These investigations included blood tests, urine
tests, ambulatory BP monitoring, cardiac investigations (e.g., echocardiogram)
and imaging (e.g., MRI). For 12 participants (25.5%), the ACC clinician arranged
follow-up, and where specified, this ranged from follow-up in 1 week (e.g., for
significant mental health issues) to 6 months (e.g., repeat routine cardiac
investigations, OA surveillance monitoring). Secondary referral was arranged in
four cases (8.5%).
Satisfaction and experience
Twenty-four (51.0%) of participants completed the short (six-item) electronic
survey evaluating their satisfaction and experience of the ACC. The primary
reasons for participants undertaking the ACC were due to a physical health
concern (e.g., past injury, joint pain) (n =4, 17%), a mental health
concern (n =1, 4.2%), a general health check-up (n =11, 45.8%), to
support the scientific advancement and understanding of the long-term health of
footballers (n =12, 50%). Most participants (n =22, 91.7%) agreed or
strongly agreed that the ACC met their expectations. Nineteen participants
(79.2%) ‘strongly agree’ with the statement ‘I would recommend the After-Career
Consultation to my (former) teammates with a health concern’. Twenty-two
participants (91.7%) agreed or strongly agreed that the ACC adds value to the
medical provision received during their football career. Participants had a
‘free-text’ option to provide suggestions to improve/alter the ACC. Seven
participants offered suggestions, and these included integrating routine blood
tests into the ACC, a request to offer more detailed mental health support and
to arrange follow-up every 5 years. One participant felt that more assistance
should have been provided for the issues highlighted during the ACC.
Satisfaction/experience of the ACC is presented in [Table 3 ].
Table 3 Satisfaction and experience (n =24, 51%)
Primary reason(s) to choose to go to the ACC (up to three
reasons permitted)
Physical health concern (e.g., past injury, joint pain)
n =4 (17%)
Mental health concern (e.g., sleep problem)
n =1 (4%)
Brain health concern (e.g., previous concussion)
n =0 (0%)
Heart health concern (e.g., blood pressure)
n =0 (0%)
General health check-up
n =11 (46%)
To support the scientific advancement and understanding of
the long-term health of footballers
n =12 (50%)
Perception and satisfaction with ACC (%)
The ACC met the expectations of the participants
92
The ACC adds value to the medical provision received during
their football career
92
Participants would recommend the ACC to ex-players
without a health concern
92
Participants would recommend the ACC to ex-players
with a health concern
92
Discussion
This study described the clinical outcomes of and recommendations to retired male
professional footballers who undertook the ACC between April 2021 and June 2023. The
prevalence of a range of health conditions was identified (e.g., clinical OA=21%,
anxiety/depression=15%, hypertension=15%) with subsequent recommendations and
referrals recorded. Participants reported high satisfaction with the ACC, and the
primary reason (50%) for attending the ACC was to support the scientific advancement
and understanding of the long-term health of footballers.
Health conditions among retired professional footballers
According to current epidemiological evidence, all-cause mortality is lower among
retired male professional footballers than among matched controls, with fewer
comorbidities such as diabetes and cancer.[5 ]
[11 ] The prevalence of
health conditions varies across the lifespan of a footballer, with mental health
issues presenting during periods of adjustment (e.g., de-selection, injury,
transition to retirement),[38 ]
[12 ]
[40 ] significant musculoskeletal
issues typically presenting earlier compared to the general population (e.g.,
aged 45 onwards),[5 ] and
neurocognitive issues emerging after the age of 65–70.[11 ]
[12 ] Within the demographic of retired
male professional footballers in this study (mean age 38 yrs) the common health
conditions identified included musculoskeletal, mental health and cardiovascular
health conditions, with no neurocognitive health conditions identified. These
findings may reflect the age profile, proximity to retirement, and injury
history of the former players included in our study.
Our study found a prevalence of 11% of knee OA, which is low when compared to
other studies among retired male professional footballers (range 9–80%).[6 ] The prevalence of hip OA was 6%,
which aligns with other studies, where hip OA ranges from 2 to 14%, although it
has been reported as high as 50%.[6 ]
[41 ] Ankle OA ranges
from 4 to 35% among retired male professional footballers,[42 ]
[43 ] with a prevalence of 6% in our
study. The method used to diagnose OA in various limb joints differs across
studies, with some relying on clinical assessment, imaging findings, or
self-reporting by study participants—or in the case of our study, a combination
of methods (clinical assessment and self-reporting). The broad-ranging
differences in findings between studies highlight the need for consistency in
data collection in order to make valid comparisons and accurate health
recommendations.
Depression, anxiety, sleep disturbance, and alcohol misuse were the mental health
issues investigated among retired male professional footballers in our study.
The prevalence of symptoms consistent with a diagnosis of generalised anxiety
disorder was 9% (n =4), with 30% (n =14) meeting criteria for mild
anxiety. The prevalence of symptoms consistent with a diagnosis of depression
was 15% (n =7), including two individuals with moderate–severe depression.
Five participants (11%) showed evidence of mild depression. These findings are
similar to those seen in a study by Fernandes et al., where prevalence of
depression and anxiety was reported in 6 and 12% of retired male professional
footballers,[39 ] but considerably
lower than rates of prevalence seen in other studies of retired male
professional footballers (35–39%) which may relate to the use of different
validated instruments to assess anxiety/depression in this population.[44 ]
[45 ] Nearly a quarter of participants
(n =11) misused alcohol in our study, which is similar to a study by
Gouttebarge et al. (18%).[45 ] A
recent study among male (n =81; mean age of 39 yrs; mean career duration
of 12 yrs) retired professional footballers from the Australian league showed
prevalence rates ranging from 11% for anxiety to as high as 69% for alcohol
misuse, which demonstrates that there may be region-specific and socioeconomic
considerations among retired professional footballers.[46 ]
No studies, to our knowledge, have specifically examined the prevalence of
cardiovascular health conditions among retired male professional
footballers.[6 ] Our study
identified hypertension among seven participants (15%), while five participants
(11%) had an abnormal ECG finding according to pre-defined criteria. There are
studies that have indirectly examined issues related to cardiovascular health in
retired professional footballers. Two studies highlighted that retired
footballers were more likely than current footballers to adopt behaviours which
may increase their risk of cardiovascular disease, for example, smoking, alcohol
misuse and poor nutritional behaviours.[41 ]
[47 ] The prevalence
of smoking in our study (4%) was lower than that seen in the general population
(13%).[48 ] Until such time as
there is a better understanding of cardiovascular health outcomes among retired
professional footballers, population-wide clinical guidelines for the management
of cardiovascular health conditions should be adopted.
Neurocognitive health concerns among retired professional
footballers
Thirteen (28%) of the participants reported being diagnosed with a concussion
during their career (average 2 concussions per player; range 1–4). Several
studies have highlighted the concerns related to the potential increased
risks of neurocognitive disorders among retired male professional
footballers, and this may be related to a history of concussion and/or
repeated sub-concussive impacts, although more research is required to
demonstrate causality.[11 ]
[12 ]
[13 ]
[14 ] While neurocognitive function
was not specifically assessed during the ACC, there were no new significant
neurocognitive concerns highlighted among the footballers, with
recommendations only made to one participant in relation to his
neurocognitive health (this was related to a pre-existing psychiatric
condition). The likely explanation for this is that the mean age of
participants was 38 years, with the mean age of retired football players in
the study by Macnab et al. 64 years.[12 ] Nevertheless, the ACC
identified several modifiable contributing factors for neurocognitive
disorders among the retired players, such as smoking[49 ] (4%), excessive alcohol
consumption[50 ] (23%) and
depression (15%).[51 ] The ACC can
be used as an opportunity to address modifiable contributing factors for
neurocognitive disorders among retired professional footballers, as has been
done in other contexts.[3 ] It may
be appropriate to risk stratify retired players based on their lifestyle
behaviours, history of concussion(s), and/or mental health disorders[52 ] and consider targeted
evidence-based interventions for those identified as being at higher risk
due to the aforementioned contributing factors.
Future directions
The retired professional footballers in this study expressed high
satisfaction rates with the ACC, similar to other after-care initiatives
offered to professional footballers.[53 ] Initiatives such as the ACC should complement existing
efforts to improve the welfare of current, future, and former professional
footballers. These efforts include, but are not limited to, effective injury
prevention methods, improving concussion management, developing mental
health literacy, monitoring player loads, and appropriate surgical
decision-making.[6 ]
[53 ] Rather than a once-off
assessment, serial follow-ups (e.g., every 5 yr) of the ACC may prove more
beneficial to retired professional footballers—as one of the participants
proposed. There are very few studies examining health outcomes among retired
women’s professional footballers, and with the rapid development of the
women’s game, this should be a priority. Accordingly, in addition to the
health domains of musculoskeletal, mental, neurocognitive and cardiovascular
health, the ACC should focus on a female-specific domain and explore
reproductive health outcomes among retired women’s professional
footballers.[54 ] Expanding
the geographical scope of interventions such as the ACC (or similar) across
multiple sports is likely to further benefit long-term athlete welfare.
Finally, considering the number of years since retirement for future ACCs is
important, given the pattern of health complaints presenting at different
times across the lifespan of a footballer, and the difference in resources
and conditions that existed for players of different generations.
Strengths and limitations
This study is the first to investigate the effect of the ACC across multiple
countries and continents. The small sample size is the main limitation of
this study, which impacts the generalisability of the findings. It is also
limited by its use of the English language only during the course of the
ACC, and its findings are limited by not including participants from
continents outside of Europe or North America. The non-randomised nature of
this study increases risk of bias, confounding and validity issues. In
particular, the risk of selection bias in this study may lead to an
over-estimation of certain health conditions among retired male professional
footballers. There was no reference or comparison group from a non-athlete
population, matched for age and gender, and this would have allowed for a
greater understanding of potential differences among retired male
professional footballers and those in the general population. Despite the
challenges of doing so, carrying out a randomised controlled trial (RCT)
would be the most effective method of understanding the true effect of
retired professional footballers undertaking the ACC.
Conclusion
This study described the clinical outcomes/recommendations for retired male
professional footballers who undertook the ACC. Participants reported high
satisfaction with the ACC. The ACC could complement existing player welfare
strategies (e.g., concussion care, load management) to provide a well-rounded
approach to managing the long-term health of professional footballers during and
after their careers. Future studies should assess the impact of the intervention
against a control group, and among women footballers.
Disclosure statement
The authors declare no relevant financial or non-financial competing interests.
Data availability statement
Data availability statement
The data that support the findings of
this study are available on request from the corresponding author.
