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Precompetition medical assessment of referees and assistant referees selected for the 2010 FIFA World Cup
  1. Mario Bizzini1,
  2. Christian Schmied2,
  3. Astrid Junge1,
  4. Jiri Dvorak1,3
  1. 1FIFA Medical Assessment and Research Centre (F-MARC) and Schulthess Clinic, Zurich, Switzerland
  2. 2Cardiovascular Centre, University Hospital Zurich, Zurich, Switzerland
  3. 3Fédération Internationale de Football Association (FIFA), and Schulthess Clinic, Zurich, Switzerland
  1. Correspondence to Dr Mario Bizzini, Schulthess Klinik, F-MARC, Lengghalde 2, CH-8008 Zurich, Switzerland; mario.bizzini{at}


Background Several proposals for preparticipation screening to detect risk factors for sudden cardiac death in sports have been published, but referees have been neglected in this respect.

Methods A standardised precompetition medical assessment (comprising a general physical, orthopaedic and cardiac examination and blood analysis) was performed in all 90 referees and assistant referees selected for the 2010 Fédération Internationale de Football Association World Cup.

Results More than a third of the referees showed at least one pathological finding in cardiac examinations; however, all follow-up examinations proved to be normal. The relatively high prevalence of pathological findings in the blood analysis and the orthopaedic examination can be attributed to the average age of the referees and none of them was performance limiting.

Conclusions Considering their risk of occult ischaemic heart disease, a precompetition medical assessment including an exercise ECG is recommended in elite male football referees.

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Several proposals for preparticipation screening to detect risk factors for sudden cardiac death (SCD) in sports were published in recent years,1,,6 including an International Olympic Committee Consensus statement on periodic health evaluation of elite athletes.7 Most literature on cardiovascular preparticipation screening focuses on the young competitive athlete, whereas sufficient specific data and guidelines for competitive athletes older than 35 years are rare.

The Fédération Internationale de Football Association (FIFA) developed a standardised football-specific precompetition medical assessment (PCMA) and introduced it for all players participating in the 2006 FIFA World Cup in Germany.4 The PCMA was subsequently requested in FIFA competitions for female and youth players and is now mandatory in all FIFA competitions.8

Referees, to the best of our knowledge, have not been regarded in any preparticipation screenings before. In football, referees experience similar physiological loads to professional players during a match but are substantially older than players.9 10 Thus, their risk for exercise-related SCD due to an underlying coronary heart disease (CHD) is increased.3 Therefore, FIFA decided to implement its PCMA also for referees selected for the 2010 FIFA World Cup. The aim of this study was to analyse the PCMA findings in this group.


The PCMA was performed in all referees (n=30, 33.3%) and assistant referees (n=60, 66.7%) selected for the 2010 FIFA World Cup at the Schulthess Clinic, FIFA Medical Centre of Excellence, Zürich, Switzerland from 24 February to 6 March 2010.

All examinations were conducted by experienced physicians and followed FIFA's standardised PCMA protocol,4 which comprises medical history, general physical examinations, laboratory blood analysis, orthopaedic and cardiac examinations (physical examination, 12-lead resting ECG, transthoracic echocardiography). To detect asymptomatic CHD which is the most common underlying cause of SCD in older athletes,3 a self-limited exercise ECG (bicycle, ramp-protocol) was additionally performed.

The ECGs were analysed according to the current recommendations of the European Society of Cardiology, and the findings were divided into unsuspicious, typically sports-associated changes and suspicious findings.11 The exercise ECGs were individually assessed according to the estimated target of effort and with respect to physical capacity, heart rate and blood pressure response, arrhythmias/conduction anomalies and stigmatas of exercise-induced myocardial ischaemia. ‘Time to exhaustion’ should be reached within 8–13 min. Exercise hypertension was defined as a systolic blood pressure higher than 200 mm Hg with an additional increase of diastolic blood pressure at a mean burden according to the maximal physical capacity. Transthoracic echocardiographies were performed and analysed following the current recommendations.12

All athletes gave their signed informed consent to participate in the study. The study was approved by the University Human Subjects Ethics Committee, University of Zürich.


On average, the 90 male referees were 39.1 (SD=3.9, range 27–44) years old, their height was 1.78 (SD 7.0, range 164–199) m, weight 77.4 (SD=7.8, range 50–98) kg and body mass index 24.4 (SD=1.7, range 16.7–27.5) kg/m2.

In the general medical history, one (1.1%) referee reported diabetes mellitus type I and one (1.1%) had hypertension under treatment. Concerning their family history, 10 (11.1%) referees reported CHD, 3 (3.3%) ‘cardiomyopathy’, 5 (5.6%) stroke, 18 (20.0%) hypertension and 18 (20.0%) diabetes mellitus. The clinical examination revealed suspicious heart murmurs in two (2.2%) cases. In 20 (22.2%) referees, the blood analysis resulted in at least one of the following findings: substantially elevated serum lipids (n=2, 2.2%), slightly elevated (less than three-times of normal) liver enzymes (n=9, 10.0%), morphologically suspicious red blood cells/erythrocytes (n=2, 2.2%), decreased platelets (n=1, 1.1%), mild anaemia (n=2, 2.2%), elevated urea and uric acid (n=3, 3.3%) and slightly elevated C reactive protein (n=1, 1.1%).

Thirty-two referees (35.6%) showed at least one pathological finding in the cardiac examinations. The main suspicious findings are outlined in detail in table 1. Of the two (2.2%) referees with suspicious heart murmurs, one had a correlating mild mitral regurgitation due to mild fibrotic changes of the valve and the other had murmur originated from a meso-telesystolic mitral valve prolapse with only minor mild regurgitation. ‘Functional’ heart murmurs with no correlation in the transthoracic echocardiography were frequent (62%). There were no diastolic murmurs and no significant variations of the heart sounds.

Table 1

Number and percentage of referees with suspicious findings in 12-lead resting ECG, transthoracic echocardiography and exercise ECG

All referees showed an excellent physical capacity during the exercise test with an average increase of the ‘ramp’ of 30.7 W/min and a mean self-limited exercise duration of 8 h 45 min. The average effort achieved was 317.4 W, equivalent to 4.11 W/kg (maximum effort: 479 W, respectively, 5.49 W/kg). No relevant arrhythmias were provoked during the exercise ECG. All referees with an atrioventricular (AV) nodal block I showed a decrease of the AV conduction during exercise. None of the referees complained about any symptoms suggesting angina pectoris, whereas four referees showed suspicious ST segment changes (normal baseline ECG and ST segment depression ≥2 mm in leads V4–V6 during maximal effort). All referees with a hypertrophic left ventricle or ‘hyper-trabeculated’ myocardium were further examined (ie, using MRI), but in none a relevant structural heart disease was found. The referee with a mitral valve prolapse had no additional risk factor according to the criteria of the 36th Bethesda Conference.13

Almost all referees (n=84, 93.3%) had at least one pathological finding in orthopaedic examination. The most prevalent pathological findings were a positive anterior drawer test of the knee (n=38, 42.2%) or ankle (n=32, 35.6%), and a positive varus stress test at 30° flexion in the knee (n=32, 35.6%). In addition, 30 (33.3%) referees had positive Lachman test, 15 (16.7%) a positive valgus stress test at 30° flexion and six (6.7%) limited flexion–extension in the knee joint. Fifty (55.6%) referees had a pathological finding in at least one knee, 24 (26.7%) in both knees. More than a quarter of the referees had limited flexion of the hip (n=25, 27.8%). Thirteen (6.7%) referees had tenderness during palpation of the Achilles tendon and six (6.7%) of the groin. Five (5.5%) referees had a surgery of the groin (n=2), knee (n=2) or back (n=1). None of the 90 referees reported a severe injury in the last year or current complaints.


This is the first report of a standardised precompetition screening for cardiac and/or orthopaedic risk factors in referees.

Although 12 (11.1%) referees showed suspicious findings in the 12-lead resting ECG, all follow-up examinations (echocardiography, MRI and electrophysiological testing) proved to be normal. None of the four referees with suspicious ST segment depressions during exercise testing showed relevant CHD (single photon emission CT or perfusion-MRI). The five referees with high blood pressure response during exercise ECG had normal blood pressure at rest, no pathological findings in echocardiography or blood analysis. The referees with diabetes mellitus type I or hypertension under treatment were in a stable condition. All referees with a ‘positive’ family history had no pathological cardiac findings. The relatively high prevalence of pathological findings in the blood analysis can be attributed to the average age of the referees.

Comparable data on cardiac screening in older athletes are rare. The mean age of the cohort of Sofi et al14 was considerably lower (30.7 vs 39.1 years) than in this study and included female athletes (21.6%). While the percentage of pathological findings in the personal history and clinical examination was similar, relevant findings in the 12-lead resting ECG (1.2% vs 11.1%) and alteration of the ST-/T-segment during exercise testing (0.1% vs 4.4%) were more frequent in this study. Sofi et al14 concluded that exercise ECG is recommended in older athletes, since 79.2% of the athletes disqualified for cardiac reasons had pathological findings during exercise ECG but a normal ECG at rest.

The orthopaedic examination revealed that about half of the referees had an increased knee and/or ankle joint laxity. However, it is well documented that pathological laxity may not cause subjective instability or related symptoms.15 16 The Achilles tendon tenderness found in 14.4% of the referees may indicate the presence of potential overuse problems. Bizzini et al17 showed previously that ankle, knee and Achilles tendon were among the most common locations for injuries and musculoskeletal complaints in elite referees.


Considering their risk of CHD, a PCMA including an exercise ECG is recommended for elite male football referees.


The authors thank the FIFA Refereeing Department for their cooperation, especially José María Garcia-Aranda and Claudio Pilot. The authors highly appreciate Dr Yacine Zerguini (Algeria), Dr Pieter D’Hooghe (Belgium), Dr Nina Feddermann, Dr Christian Hagne and Dr Martin Schläpfer (Switzerland) for their assistance with the medical history and physical examinations. The authors thank the Sports Medicine Department of Schulthess Clinic for their collaboration.



  • Funding The authors thank FIFA (Fédération Internationale de Football Association) for the funding of the study.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed