Abuse of medication during international football competition in 2010 – lesson not learned
- 1F-MARC, (FIFA Medical Assessment and Research Center), Schulthessclinic, Zurich, Switzerland
- 2Surgical Department, Canton Hospital Winterthur, Winterthur, Switzerland
- 3Fédérations Internationale de Football Association, Zurich, Switzerland
- Correspondence to Philippe Matthias Tscholl, F-MARC, Schulthessclinic, Lengghalde 2, CH-8008, Zurich, Switzerland;
Contributors Every author contributed substantially to this publication.
- Received 26 November 2011
- Accepted 9 February 2012
- Published Online First 22 March 2012
Background The use of medication in professional football has previously been shown to defy clinical guidelines.
Materials and methods Physicians of the teams who participated at the 2010 FIFA World Cup provided the list of medications used by each player within the 72 h preceding every match.
Results During the tournament 71.7% of all players took medication, and 60.3% (444 of 736 players) took painkilling agents at least once. Over a third of players (39.0%) took a painkilling agent before every game. More medications were used during the finals than during the qualifying round of matches (pool games) (0.87±0.09 vs 0.77±0.03, p<0.01). Players from North and South America took almost twice the number of medications than did players from other continents (1.18±0.08 vs 0.64±0.03; p<0.01).
Conclusion The use of medication reported by the team physicians in international football competition is increasing. Systematic use – medication for every match – appeared to be the norm in certain teams. This has implications for player health. These data encourage efforts to better understand, and to address, this potential disastrous practice in professional sports.
Previous reports have documented the use of medication in International Football for male, female and youth players,1,–,4 for Olympic Games5,–,7 and other sports events.8,–,10 The key determinants associated with the use of a larger number of medications in team and individual sports events were geographical origin and certain team physicians.11 There was only small correlation with age, and no correlation with team-success, previous or current reported injury on the F-MARC (FIFA Medical Assessment and Research Center) injury form and minutes played during the tournament.2 ,9 ,11 On several occasions, preventive measures were undertaken from the official medical board of FIFA, where team physicians were informed and alerted to the high use of non-steroidal anti-inflammatory drugs (NSAIDs). Guidelines exist to guide sports-physicians prescribing behaviour.12 ,13
The main goal of this study was to compare the use of medication in international football in 2010 with previous competitions.
Identical methodological approach was used as in previous studies.2 ,3 During the 2010 FIFA World Cup in South Africa, the use of prescribed medication by each player during the 72 h preceding each match was recorded by the team physician. The substance-groups were as follows: NSAIDs, analgesics, injected corticosteroids and local anaesthetics, muscle relaxants, respiratory drugs, medication for gastrointestinal and antimicrobial purposes and others.
Thirty-two countries took part in this tournament, which nominated 23 players each (736 players in the tournament) and participated in 64 matches (2944 player matches).
The results were calculated as follows:2 ,3 (1) substance/player (mean intake per player per match or per tournament) and (2) number of individual player reported to be using a substance (per match or per tournament).
The statistical methods applied were frequencies and cross-tabulations. Significance was considered at p≤0.05.
On average, players took 0.8 medical substances before each match. More than two-thirds of all medication were in the following drug class: oral analgesics (NSAIDs: 49.0% (n=1144), other analgesics: 10.5% (n=246): 2.3% local anaesthetic injections, n=53), muscle relaxants: 3.8% (n=88)); 84.3% of all NSAIDs were cyclo-oxygenase (COX)-I-inhibitors and 15.6% were COX-II-inhibitors. Corticosteroid injections were given to 2.4% of players (n=55).
Nearly half of all players (48.2%), regardless whether they participated in the match, took some sort of medication and to more than one-third (34.6%) of the players at least one NSAID was prescribed before a match. Thirty-two intra-articular, 20 intra-muscular, wherefrom five lumbar and three peritendinous glucocorticoid injections were reported in 25 different players, administered within the 72 h preceding the match; 7.2% of players took at least one antibiotic at some stage during the tournament.
Comparing the final rounds (16 teams) with the qualification rounds (32 teams), the rate of medication per match and per player was significantly higher (0.87±0.09 per match/per player vs 0.77±0.03, p<0.01). This was driven by a higher use of NSAIDs (0.46±0.05 vs 0.36±0.02; p<0.01) and more injections of corticosteroids and local anaesthetics (0.06±0.01 vs 0.03±0.01; p<0.01) When we examined regional patterns, the continents of North and South America had significantly the highest reported use of medication per match and per player (1.18±0.08 and 0.64±0.03, respectively; p<0.01). Differences in prescription practice varied enormously among countries. The range of medication reported was from 0.22 to 3.13 per player per game; NSAID prescription ranged nearly 20-fold – from 0.06 to 1.17 NSAIDs per player and per match.
These data from the 2010 FIFA World Cup show that there was no change in the high use of medication despite several preventive measures. As reported for the 2002 and 2006 FIFA World Cup, 0.8 medical substances were reported per player and per match, and about 54% of all players reported to use NSAIDs at least once during the tournament. However, the number of players taking NSAIDs per match increased significantly (p<0.01, see table 1). However, there is emerging evidence that prolonged use of NSAIDs can lead to impaired bone14 ,15 and tendon healing,16 ,17 recruitment of satellite cells of skeletal muscle18 and systemic side effects.10
Although the use of inhaled β-2 agonists per player and per match increased significantly over time in FIFA World Cups (p<0.01, see table 1), its use is still small compared with other sports.6 ,8 ,10 ,19
Continental differences seem to be less important in international football than in track and field9 most probably due to the low number of physicians participating at a FIFA World Cup compared with a single sports event. However, the differences between the countries were significant and striking. Whereas most of the team physicians did not perform injections with glucocorticosteroids (23 of 32), in one team, three to four players had peritendinous or intra-articular injections before each game with glucocorticosteroids. Also, the use of NSAIDs seems to be strongly depended on the team physician.
The use of medication reported by the team physicians in international football competition is high, and still seems to be increasing. The major problems are NSAIDs. Systematic use of NSAIDs was found in a few teams. Also, regular administration of intra-articular corticosteroid injections before a match needs to be questioned and further investigated. It is unclear whether this intake might also be partially due to a ritual by the players.
These timely data suggest that medications are widely prescribed in elite sport and this may not be consistent with guideline advice or even biological plausibility. Given that elite players and physicians working at the elite level are role models, it is clearly time to seek alternative management methods. There is a need for better and safer methods for performance continuation in professional athletes, and to start respecting biology when administering medication.
The authors gratefully acknowledge FIFA (Fédération Internationale de Football Association) for funding this study. The authors express our gratitude to the members of the FIFA Sports Medical Committee (Chairman: Dr M D'Hooghe) for their support.
Funding FIFA (Fédération Internationale de Football Association).
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.