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Put out to pasture: what is our duty of care to the retiring professional footballer? Promoting the concept of the ‘exit health examination’ (EHE)
  1. Sean Carmody1,2,
  2. Christopher Jones3,
  3. Aneil Malhotra4,
  4. Vincent Gouttebarge5,
  5. Imtiaz Ahmad2
  1. 1 School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
  2. 2 Medical Department, Queens Park Rangers Football and Athletic Club, London, UK
  3. 3 Isokinetic Medical Centre, London, UK
  4. 4 Cardiovascular Sciences Department, St. George’s University of London, London, UK
  5. 5 Medical Department, World Players’ Union FIFPro, Hoofddorp, The Netherlands
  1. Correspondence to Dr Sean Carmody, Medical Department, Queens Park Rangers Football & Athletic Club, London, W12 7PJ, UK; seanocearmaide{at}gmail.com

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Retired professional footballers are at a significantly increased risk of several health problems including osteoarthritis,1 mental health conditions2 and difficulties pertaining to suboptimal lifestyle choices.3 The aim of this editorial is to highlight the health issues faced by players in retirement, to advance the concept of the ‘exit health examination’ (EHE) and to promote the duty of care that clinicians, clubs and governing bodies have to ensure that the risk of poor long-term health outcomes is minimised.

‘Side effects’ of a career in professional football

Professional footballers are prone to recurrent and severe musculoskeletal injuries, which can occasionally be career-ending.4 Although these can in themselves increase the likelihood of developing osteoarthritis, they may also require surgical intervention, which heightens the risk.

Several studies have highlighted the increased prevalence of hip, knee and ankle osteoarthritis among ex-footballers compared with the general population, with much earlier onset of disease and increased likelihood of joint replacement reported.1 The presence of osteoarthritis in ex-footballers is associated with a poorer health-related quality of life and an increased risk of mental health disorders.2

Mental health disorders are more frequent among ex-professional footballers than their counterparts; up to 39% report symptoms related to depression and anxiety over a 12-month period.2 Mental health problems tend to peak soon after retirement, which may suggest vulnerability during the transition period.

When assessing cardiovascular disease in professional footballers, the focus shifts from inherited and congenital causes of sudden cardiac death in those aged 14 to 35 years, to coronary artery disease in those aged over 35 years. The cessation of an athletic career may herald a less healthy lifestyle, including a reduction in exercise, increased alcohol intake, unhealthy nutrition choices and smoking.2 These can all increase the risk of coronary artery disease.

Medication overuse, in particular non-steroidal anti-inflammatory drugs, has been raised as an issue in professional football.5 A history of medication overuse may promote dependence in retirement.6

Exit health examination

We believe retired players should have the benefit of a formal EHE to guide the player’s choices for health in later life. Despite the continuous growth in resources invested in managing a player’s health during his or her career, to our knowledge, there is little consideration given to long-term health. With the evidence base for preventative strategies increasing, the opportunity should be taken to proactively reduce the risk of health issues in retirement. Both current and retired professional footballers have expressed a desire for this level of care.3 7

A proposed format for the EHE has been attached as an online supplementary appendix 1 to this article. It is currently within the scope of practice of club physicians to lead EHEs, and this process should be supported by the relevant football associations as has happened in the past for initiatives such as cardiac screening. Once the EHE is performed, consent should be obtained to transfer records securely to the player’s named general practitioner. In future, EHEs may be led by an established network of independent physicians nominated by the World Players’ Union (FIFPro), with the results uploaded to a central registry, and where appropriate, research could be undertaken to improve our understanding of the health implications of a career in professional football in a similar manner to the Football (NFL) Players Health Study at Harvard University.

Supplemental material

In collaboration with FIFPro, the Dutch Players’ Union VVCS and the Dutch FA have led the development of an EHE pilot study (so called ‘After Career Consultation’) to improve the health and quality of life of retired professional footballers. This initiative must be supported by an integrated approach from all stakeholders working in football to ensure that the duty of care towards active professional footballers extends to safeguarding long-term health.

Call for action

It is well recognised that retired professional footballers are particularly susceptible to several physical and mental health problems. Stakeholders have a duty of care to consider how to protect the long-term health of professional footballers during their careers, and this should be complimented with a formal EHE. It is reasonable to conclude that such an approach may lead to better health outcomes and improved quality of life in the retired footballer.

Nevertheless, more research is needed to understand the long-term effects of playing professional football and which, if any, primary and secondary prevention strategies may be appropriate to implement during and after a player’s career. Additionally, gold-standard practice for an EHE must be established; we provide a first iteration of that here. There is a need for consensus as to how such an intervention should be led and funded, with defined roles for governing bodies, clubs, players’ associations and clinicians working in football. It is hoped that such research will pave the way for a renewed focus on the retired athlete across all sports.

References

Footnotes

  • Contributors The idea, planning and composition of this article was contributed to by all listed authors. The final manuscript was proposed by the first author and agreed on unanimously by all others. There were no further collaborators involved in the process.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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