ISSN: 1543-9518|Vol. 24

Male Competitive Powerlifters relationship with Body Image: Utilising the Multidimensional Body Image Self Relations Questionnaire (MBSRQ)

Authors: Dr. Mark Chen1, Dr. Andrew Richardson2

1School of Health and Life Sciences, Teesside University, UK (corresponding author)
2Population and Health Sciences Unit, Newcastle University UK

Corresponding Author:

Corresponding Author: Mark Chen
Campus Heart, Southfield Road, Middlesbrough
TS1 3BX, Tees Valley
m.chen@tees.ac.uk

Dr Mark Chen is a Senior Lecturer in Sport and Exercise Science at Teesside University and is a Chartered Psychologist with the British Psychological Society (BPS). Dr Chen’s research interests include psychological consequences of sports injury and attentional aspects of sports performance.

Dr. Andrew Richardson is a Chartered Heath and Activity Practitioner with the Chartered Institute for the Management of Sport and Physical Activity (CIMSPA) and is currently a Research Associate within the Population and Health Sciences Institute at Newcastle University. Andrew’s other research interests include body image, performance enhancing drugs, transgender sport, esports and public health..

Male Competitive Powerlifters relationship with Body Image: Utilising the Multidimensional Body Image Self Relations Questionnaire (MBSRQ).

ABSTRACT

Purpose: There is growing evidence to suggest that competitive male athletes in aesthetic sports that scrutinize their body image may experience undesirable mental health outcomes. However, there is limited research to address these issues in strength sports, particularly the sport of Powerlifting. Methods: This study employed the Multidimensional Body Image Self Relations Questionnaire (MBSRQ), which recruited 365 male participants across the following subgroups. Powerlifters (P) (n = 133), Active Subjects (AS) (n = 79), Appearance Based Sports (ABS) (n = 68), Strength Sports (SS) (n = 47) and Other Sports (OS) (n = 38). Results: One–way ANOVA showed significant (p < 0.05) results between all groups across six of the nine MBSRQ subscales. Post hoc comparisons found nine significant results with the powerlifting group achieving two of them against OS (p < 0.01) and AS (p < 0.01) groups respectively. Conclusions: Overall, the results showed that male powerlifters expressed their bodies-as-function rather than their bodies-as-object with regard to health evaluation and fitness orientation. This is supported by their stable and balanced scores across the MBSRQ subscales which indicates they have healthier and lower perceptions of negative body image concerns. The powerlifters results implied that a focus on objective performance improvement and maintaining a healthy body to prevent injury had body image benefits. Applications in Sport: The study concludes that male powerlifters present healthy body image perceptions compared to the other males in their respective sports and focus on their body functionality objectively rather than the subjective perception and presentation of their body image.

Keywords: Powerlifting, Body Image, Weight Classed Sports

INTRODUCTION

For this paper, the definition of Body image is referred to as “relating to a person’s perceptions, feelings and thoughts about his or her body, and is usually conceptualized as incorporating body size estimation, evaluation of body attractiveness and emotions associated with body shape and size” [1-2]. There has been extensive work conducted on the influence of body image in the media [3], in Western culture [4] and job roles such as the fitness industry [5]. Other comparisons include comparing body image within a range of demographic factors such as between athletes and non-athletes [6], age [7], nationality and ethnicity [8]. Cash and Pruzinsky [9] have defined five dimensions of body image, which work together to create an overall body image. However, these dimensions fails to mention the broader cultural and social contexts that influence body image [10]. They suggested that athletes dealing with sporting and societal pressures may experience adverse outcomes such as eating disorders or a negative perception of their body image. Such factors may lead to these pressures as a result of media and advertisements [11], supplements [12] and the use of image and performance-enhancing drugs [13].

Background of Powerlifting

Powerlifting athletes are scored on objective performance measures rather than appearance evaluations. Powerlifting tests athletes on their objective strength and has traditionally been male-dominated [14]. However, in the last twenty years, female participation has significantly increased [15]. Richardson and Chen [16] state that powerlifting is a competitive strength sport comprising three techniques: the Squat, the Bench Press and the Deadlift [17-18]. The aim is to lift the most weight across the three movements for nine attempts [18]. Sports similar to powerlifting that heavily rely upon strength include Olympic weightlifting [19], strongman [20], highland games [21] and the shot–put [22], to name but a few examples. Not all of these sports mentioned have a weight class or a weight requirement, but for those that do, depending on the rules of the competition, this weight requirement may be evaluated within twenty-four or even forty-eight hours prior to the event [23]. Weight classes help ensure fairness in competition and increase the pre-competition demands of participants to enter the weight category that maximizes their advantages. Experts argue that making weight places psychological demands on athletes who may be inclined to make drastic weight cuts to gain a competitive advantage [24]. However, as powerlifters are evaluated on the amount of weight lifted, the training is based on objective scoring criteria. As scoring is objectively determined, and not a third party as in aesthetic sports, this has important implications for positive psychological adaptations [25].

Theoretical models and frameworks

Theoretical models of body image, such as Objectification theory, focus on the impact on men of a culture that increasingly objectifies men’s bodies. It suggests that men, like women, may experience self-objectification [26]. For men, the dual focus on both leanness and muscularity characterizing the male body ideal may motivate a particularly maladaptive set of behaviors designed to achieve these goals, such as rigid exercise routines, hidden use of image and performance-enhancing drugs (IPEDs) [27]. Subsequently, the literature has claimed that men may suffer from body image concerns and dysfunctional behavior [28]. Some research argues that young men experience societal pressure to achieve the muscular mesomorphic body shape, and this behaviour leads to a drive for muscularity [29].

Further, studies have demonstrated that sociocultural pressures mediated by social comparisons and internalization of muscular and low-fat ideals are associated with men’s body dissatisfaction and drive for muscularity, which might lead to disordered eating [30]. Most research has focused on aesthetic sports such as bodybuilding [31-32]. These explanations fail to consider how individuals think, feel and behave concerning their body functionality [33]. How powerlifters think, feel, and behave about their body functionality in a sport concerned with achieving objective demands is essential to achieving a more complete and holistic understanding of body image in this context [34].

Theoretically, the subjective perception of muscularity depends on the individuals’ perception of body image, which for powerlifting tends toward a functional muscularity rather than aesthetic muscularity due to the sport’s rules. Critically, the self-objectification model does not consider the functionally orientated nature of sporting competition and its impact on male psychology [35]. Therefore, the athletes have a strong sense of control and need to prepare, train and diet concerning maximizing objective performance criteria, not gaining approval from judges based on aesthetics. The environmental demand to achieve an objective standard has essential implications for broadening body image, as Ginis et al., [36] reported. They found that the idea of muscularity and physical competence in men [37] are central to their evaluations of their bodies.
According to Conceptualisation theory, men are socialized to focus more attention on their body functionality than body-as-object (image) [38]. Therefore, powerlifting males are likely to value the functionality of their body over appearance, not only due to socialization processes that favour the achievement of tangible performance-based outcomes [39-40] but also due to the specific environmental demands of powerlifting which reward objective performance results. In contrast, perceptions of leanness and body fat percentage are less relevant to powerlifters performance. Franzoi [38] defined body-as-process as comprising physical capabilities and internal processes, which is similar to body functionality. The demand for functionality adds sources of experience, such as training to execute specific external and internal demands, that requires knowledge of body functionality (movement) and is, therefore, adaptive for how male powerlifters individuals think and feel about their body image [38].

For example, Richardson and Chen [16] found that female powerlifters, despite presumably having been socialized to experience higher levels of self-objectification and greater body-as-object identification than men, as predicted by self-objectification theory, nevertheless enjoyed their appearance in their sporting environment, indicating that it was not a source of anxiety, presumably due to the enjoyable experience of functional powerlifting training and competition reward. This was evident in other studies using smaller sample sizes and qualitative interviews in the same sport and sex [14 & 41]. Bordo [42] found that individuals who presented with large muscular physiques symbolized strength and masculinity.

Competition achievement and social reward within a sport based on tangible athletic goals [43-44] and psychological characteristics such as aggression when preparing to lift [45] will strongly mitigate against excessive rumination around body appearance and identity. Further reasoning supports the powerlifting community’s emphasis on body functionality [46-47]. From this perspective, male powerlifters likely develop a functional appreciation of their body that is valued separately from its appearance. This construct of functionality appreciation has only recently been investigated in the context of positive body image. It is positively associated with positive body image facets, such as body appreciation [48].

Franzoi [38] proposed that individuals hold more positive attitudes toward their body functionality than their body image. Therefore, it can be predicted that males with this orientation will hold performance adaptive attitudes toward their bodies. Body conceptualization theory offers a rationale for the body functionality being adaptive and reflective of positive male body image and improved mental health, compared to a body image orientation. This theorizing gives scope that negative body image attitudes can be adaptive and motivational within a performance-based environment based on objective rather than subjective and image-based criteria. For the male powerlifters, this would be the performance their bodies execute to meet the environmental needs (e.g., the sporting demands of their event). For example, Gattario and Frisen [49] found that males stated that finding a social context in which they found belonging and acceptance that allowed them to develop agency and empowerment allowed them to move from a negative to positive body image. With this logic, it could be predicted that competitive powerlifters will differ in their positive body image compared to individuals who are active but don’t compete.

Nevertheless, functionality measures have focused predominantly on physical capacities and internal processes and have typically concerned physical strength and muscularity. These aspects of body functionality can be conflated with physical appearance and are accentuated by male appearance ideals and the male gender role emphasizing dominance, power, and strength [50-51]. There has been some research into the body image perceptions of athletes in strength sports. Goltz et al [52] divided 156 male athletes into weight-class sports, endurance sports and aesthetic criteria sports and found no differences in body shape concerning self-depreciation due to physical appearance. Richardson and Chen [16] found no association between negative perceptions of appearance for female powerlifters compared to aesthetic sports individuals. These results suggested that the powerlifting group had contentment with their appearance, perhaps due to the decreased emphasis on body image compared to the increased emphasis on body functionality and focus on improving their skills and strength for their sport.

Apart from these few studies, research has yet to be done on body image and functionality in male powerlifting. The association of the physical body with functional sporting competition achievement based on objective standards may reduce the potential for internalizing negative body image and lead to healthy adaptations based on physical demands. This research will explore what functionality means for male powerlifters and how this impacts body image and functionality. This study aims to compare the body image of male powerlifting athletes against other subgroups of male athletic participation. The aim is to examine if male powerlifting athletes express different body image satisfaction or dissatisfaction with their body image and weight compared to subgroups of active and or sporting males.

Aim and Objectives of the Study 

Aim

To compare the body image differences of male powerlifters against a range of male athletic subgroups. 

Objectives

● The first objective was to determine if the powerlifters have significantly lower scores regarding their bodyweight perception when compared to other male groups in the study.

● To determine if powerlifters present an emphasis on body-as-process rather than body-as-object.

METHODS

Participant Information

An opportunity sample of 365 males was recruited through Facebook and Instagram. The recruitment period lasted three weeks in length and generated the following subgroups. There were 133 Powerlifters (P), 79 Active Subjects (AS), 68 Appearance Based Sports (ABS) participants, 47 Strength Sports (SS) participants and finally, 38 Other Sports (OS) participants within their respective subgroups. The group sample means and standard deviations for their age were 28.65 (± 7.44), height was 178.58cm (± 13.3cm), and their weight was recorded at 89.99kg (± 18.20kg). 

Within Table 1.0, each subgroup’s means and standard deviations were recorded for their age, height, weight and the length of time they have spent training. The powerlifting (P) group mean age was 27.71 ± 6.86 years, the mean weight was 92.73kg ± 21.24kg, and the mean height was 176.67 ± 15.27cm. Appearance Based Sports (ABS) group mean age was 28.04 ± 7.59 years, mean weight was 86.89 ± 14.55kg, and height was 177.11 ± 12.32cm. The active Subjects (AS) group’s mean age was 30.30 ± 8.19 years, the mean weight was 84.99 ± 12.81kg, and the mean height was 179.85 ± 14.91cm. The strength Sports (SS) group’s mean age was 29.19 ± 7.26 years, the mean weight was 97.41 ± 20.11kg, and the mean height was 181.69 ± 7.02cm. In the final subgroup Other Sports (OS) group, the mean age was 28.95± 7.49 years, the mean weight was 87.19 ± 15.53kg, and the mean height was 181.47 ± 7.87cm. No ethnic identity data was recorded. The study was conducted after obtaining ethical approval from the Teesside University School of Social Science Business and Law Ethical Approvals Committee. 

Measures 

Multidimensional Body Self Relations Questionnaire (MBSRQ): The MBSQR measures Body Image divided into cognitive and behavioral components [53]. Items are ranked on a 1 to 5 Likert scale, where 1 = Definitely disagree, and 5 = Definitely agree. The MSBRQ subscales include Appearance Evaluation (AE), Appearance Orientation (AO), Fitness Evaluation (FE), Fitness Orientation (FO), Health Evaluation (HE), Health Orientation (HO), Illness Orientation (IO), Body Areas Satisfaction (BASS), Overweight Preoccupation (OWP) and Self-Classified Weight (SCW). Illness Orientation is not included as a separate subscale, as it is already reliably accounted for under Health Orientation. The MBSRQ is significantly evidenced in Body Image research [9 & 53] as a well-validated measure [54] through comparison with other tools of Body Image. The MBSRQ has a proven reliability and validity record for body image research [53]. The composite reliability was calculated using an SPSS Omega Macro [55] and is within the acceptable range (Cronbach’s omega = 0.79). The primary author constructed demographic questions to collect information about the participant’ background. These questions included (but were not limited to) sex, age, height, weight, and years spent training. 

Procedure

Both the MSBRQ and Demographic Questionnaire were developed using Google Documents. Data gathered was stored under the General Data Protection Act [56]. Participants were assigned to groups 1.00 (Powerlifters – P), 2.00 (Appearance Based Sports – ABS), 3.00 (Active Subjects – AS), 4.00 (Strength Sports – SS) and 5.00 (Other Sports – OS), based on their answers from the demographic questionnaire. Participants were given no monetary or external incentive to take part. Participants read the pre-questionnaire information, participant information form and questionnaire instructions. Once read, participants were prompted to check a box that confirmed their consent to the study. All participants completed the questionnaire individually and received no communication from the researcher during data entry. A glossary was provided for technical terminology. Demographic questions were formatted as short answers, rating scales, and multiple-choice. Participants were informed they could opt out anytime during the study for any reason. In total, the questionnaires took about 10-15 minutes to complete.

Data Analysis

An independent group design was used to investigate the differences between the MBSRQ scores of the four. The dependent variables measured the differences in body image between the groups across nine subscales. All data were analyzed using Microsoft Excel version 2016 and Statistical Package for Social Science (SPSS) Version 27. Means and Standard Deviations were calculated for all the subscales. Data were checked for equality of variance between groups and assumptions for the one–way ANOVA where the alpha value was set at 0.05. Post hoc tests were calculated to compare the powerlifting group with the other three groups across the MBSRQ subscales. The post hoc alpha values were corrected for type one error rates using p < 0.01. To estimate the effect size of post hoc mean differences between groups, the Cohens d statistic size was interpreted using the following guidelines: .00-.2 (small), .40-.79, (medium) and .80 + (Large) [57] and 95% Confidence Intervals (CI) were reported. The Hedges g statistic was used if one or both groups being compared had n < 20, otherwise, Cohens d was reported.

RESULTS

The descriptive statistics associated with the MBSRQ scores across the five groups are reported in Table 2.0. It can be observed that the powerlifting group was associated with higher, consistently stable and healthy body image scores in comparison to the other four male sub-groups. Six of the nine MBSRQ subscales reported p-values below 0.05.

The descriptive statistics associated with the MBSRQ scores across the five groups are reported in Table 2.0. It can be observed that the powerlifting group was associated with higher, consistently stable and healthy body image scores in comparison to the other four male sub-groups. Six of the nine MBSRQ subscales reported p-values below 0.05.

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Below are the graphs of the nine subscales from the MBSRQ presented to showcase the differences in mean scores for each domain of body image.

DISCUSSION
This study aimed to compare the body image of male powerlifters with sporting and physically active males. There were multiple significant results across six of the nine MBSRQ subscales between the groups. Overall, the results of this study suggest that male powerlifters have a healthy relationship with their physical body when compared to all other groups. The powerlifters on average, evaluated both their health and fitness orientation were higher compared to both physically active males and males in other sports. Comparing the groups anthropometrics, all groups expressed similar heights, weights and mean age. Most participants from the powerlifting group were in the late twenties, average weight at 92.73kg and standing around 178cm in height. Nolan, Lynch and Egan [58] used a male sample that was comparable to the current study in size and age. Other studies recruiting male powerlifters all had smaller sample sizes and younger age ranges [59-60] compared to the current study.

The first objective was to determine if the powerlifters had significantly lower scores regarding their bodyweight perception when compared to other male groups in the study. There was no evidence to support this prediction, as the powerlifting group levels of overweight preoccupation and self-classified weight area satisfaction were not significantly different from the other groups. The Powerlifting group had scored 2.49 for the OWP subscale which was higher than both SS and OS groups but lower than AS was the powerlifting and ABS groups. This would appear to indicate that the male powerlifters either do not ruminate on their body-as-object to the detriment of their mental health or that the nature of engagement with the powerlifting competitive demands lends itself toward a functional conceptualization of the body over an image-based focus [61]. These results taken together do not imply that powerlifters demonstrated a negative perception of their body image. Rather, the results suggest that powerlifters link their body image toward objective performance related goals. Although, this is speculative, the intense regime of powerlifting training for competition would result to improved perceptions of body image due to perceived changes in strength over time.

Theoretically, powerlifters interpreting their body-as-process rather than the body-as-object is consistent with larger differences in Fitness Orientation, Health Evaluation and Overweight – Preoccupation compared to the sport male and physically active male groups. These subscales relate more to objective performance concerns, such as physical capacity, rather than the subjective interpretation of body image, thus appear to be accentuated by perceptions of power and strength [50-51]. Fitness orientation refers to, “Extent of investment in being physically fit or athletically competent. High scorers value fitness and are actively involved in activities to enhance or maintain their fitness. Low scorers do not value physical fitness and do not regularly incorporate exercise activities into their lifestyle” [53]. Richardson and Chen [16] found their sample of female powerlifters scored the highest out of this subscale when compared to other groups.

Health Evaluation is defined as, “Feelings of physical health and/or the freedom from physical illness. High scorers feel their bodies are in good health. Low scorers feel unhealthy and experience bodily symptoms of illness or vulnerability to illness” [53]. Richardson and Chen [16] found that their sample of female powerlifters scored the highest on this subscale compared to other sporting females.

Overweight preoccupation reflects “fat anxiety, weight vigilance, dieting, and eating restraint.” [53]. Richardson and Chen [16] found, for their powerlifting group, very stable scores around the normative values with little deviation from the mean, therefore indicating that the group were happy and content with their weight for the function of powerlifting. The Powerlifting group had higher OWP compared to the other two groups but not low enough to indicate extreme weight cutting, dieting or weight anxiety, Although, the nature of powerlifting does require some weight monitoring due to the weight classes requirement, the score was not concerning. An individual-by-individual analysis would need to be considered to accurately assess if an athlete is expressing extreme body weight anxiety or concerns.

Certainly, this does contrast with the findings of the Active subjects (AS) group who had a moderate effect size of greater overweight preoccupation (OWP) and self-classified weight (SCW) compared to Other Sports (OS) and Strength Sports (SS). These difference of the control group (AS) adds further weight for the difference between the powerlifters and the other groups body image. The active subjects were composed of individuals who don’t compete in any sport, but their recreational exercising still did not prevent them from having pre-occupation with their physique. Male exercisers can be as pre-occupied with outward appearance as women due to their motivation for muscularity [62] and also as non-athletes they may lack the functional body appreciation that male athletes possess [63].

The second objective was to determine if powerlifters present an emphasis on body-as-process rather than body-as-object. Theoretically, body functionality can be understood in contrast to appearance ideals and gender roles for men, which emphasise the importance of physical strength, prowess, and bodily control [64]. The absence of negative body image perceptions in the males only lends indirect evidence for a higher emphasis on functional cognitions related to objective performance. There were two significant differences between powerlifters with OS and AS in health evaluation and fitness orientation. There was a moderate effect size difference for health evaluation, with the powerlifting group showing more robust health behaviours than the other sports group.

The other sport group was the smallest group (n=31) and consisted of people who recreationally participated in a variety of sports of which Soccer, Cross fit and Athletics were the most numerous. The health cognitions of the powerlifters place an emphasis on being prepared to execute maximum effort in their training and respecting the possibilities and limit of what they can achieve [65]. Compared to sports such as Athletics and Soccer, which place more emphasis on diverse interceptive open skills in a changing environment and / or endurance, Powerlifting requires maximum and intense concentration to prepare for one explosive movement. Therefore, the powerlifters need to have a healthy attitude toward diet, for example, as performance is related to performing at their physical limits but is not essential for skilled footballers. These results contrast with Goltz et al., [52] who found no differences in self-depreciation due to physical appearance in comparing weight-class sports, endurance sports and aesthetic criteria sports.

The powerlifting group also showed stronger fitness orientation compared to the active subjects groups. This may mean that the powerlifters monitoring of their pre-performance health results in stronger fitness evaluations compared to individuals who only exercise and also individuals in sports with less physically explosive demands [65]. This seems to reinforce the first finding, that male powerlifters have a positive rather than negative view of their body image, in terms of the value they place on health and fitness related cognitions to help prepare for competition. The fitness-orientation aspect can be interpreted for body functionality qualities, as this subscale would support behaviours and cognitions conducive to maintaining good physical condition and a positive view of the body [66]. An explanation in terms of body conceptualization theory is that the functionality of powerlifting competition allows the participants to engage in a wider range of strategies to maintain fitness rather than being concerned with aesthetics, compared to individuals who only exercise [49].

Comparing this to the appearance-based sport (ABS) group, they too also undergo intense and regimented training, as competitors will need to ensure they are in the best condition for competition, although still based on aesthetics. However, where the ABS group differ from the powerlifters is a moderate effect size for overweight preoccupation compared to the OS group. There was also a moderate effect size for self-classified weight compared to the strength sports group. These two subscales are more in line with previous findings [67], in that aesthetic sport participants need to put more effort in body monitoring and judgements related to weight loss or gain. In powerlifting, research has shown that to overcome confounding issues that may affect athletic performance, athletes reported that the following factors help relieve or reduce competition day stressors include, the coach, mental attitudes, technical instruction, training partners and social isolation [67]. When comparing between sexes, the results revealed no fundamental difference in these confounding factors by male and female powerlifters [66]. Within both studies, it was noted that there was no mention of body image when competing to be a compounding factor, which supports the current findings. Nevertheless, the powerlifters body image or perception of their own image was not given as an option in their studies so results may have been different if participants had been given an option to select.

The AS group reported two medium effect sizes against the other sports group and strength sports group, which were in the overweight preoccupation and self-classified weight subscales, but the powerlifting group scored a moderate effect size against the AS group in fitness orientation. The reason for this can be linked to multiple variables. Firstly, the AS group participants as stated earlier in this manuscript are not training to improve their performance within a specific sport or event. They are active males who are training but with no sport specific goal in mind. Hence, these individuals may be more critical of themselves when it comes to focusing on their bodyweight. This can be easily demonstrated in the subscale of SCW where the AS group scored the lowest when compared to the OS and SS groups. As individual in these sports may compete at a weight they are comfortable at, this yields them the best performance advantages when in competition.

Notwithstanding, the AS group did score closer to a mean normative value for their OWP subscale and scored higher than both OS and SS groups. The reason may be that higher scores focus more on weight vigilance and weight anxiety. However, the OS and SS groups scoring lower than AS and having low OWP scores indicates that their sports don’t require, or these athletes didn’t express any worry about their weight when competing.

Nevertheless, there is research to suggest that those who train for body image and pursue masculine muscular ideals may be motivated for these appearances through unhealthy means. These include self – blame and or internalised shame as reported by Larison and Pritchard [68] found that men who scored higher on these variables also reported higher levels of eating disorder symptomology. Yet, in the same study, those same men who scored higher for internalised shame also scored higher on the drive to be more muscular. Finally, Swami and Bedford [69] found that men’s drive for muscularity was significantly predicted by neuroticism and their drive for body appreciated was significantly predicted by neuroticism and extroversion when considering BMI and subjective social status as drivers. However, in other studies the opposite findings have been reported. Reina et al., [67] also reported that males in non-aesthetic sports were more dissatisfied with their body image and were 1.5 times more likely to use exercise to lose weight than non-sport participants.

Limitations
The MBSRQ is a valid and reliable and well stablished body image assessment tool and is appropriate for out study [53]. Nevertheless, the MBSRQ does not measure disordered eating or specific ideals of muscularity as compared to other aforementioned assessment tools. The powerlifting group in this study as in the female study by Richardson and Chen [16] is centred around one sport and unlike the other groups they are made up of multiple sports. Ultimately, this will have impacted their scores within their groups and comparing between groups. The powerlifting group as a whole had more training experience than the other groups which is reflected in their larger sample size and more stable scores which has to be factored into the analysis.

CONCLUSIONS
In summary, the findings report the powerlifters presented with stable and positive outlooks and evaluations of their body image. This highlights a productive relationship with their own body image and their sport of powerlifting as a body-as-function role instead of body-as-object [47]. Comparing the powerlifters with other sport groups showed similar results. The powerlifters presented with significantly (p < 0.05) better scores for HE and FO subscales in the MBSRQ when compared to the AS and OS groups. The majority of the groups displayed stable MBSRQ subscale scores and healthy outlooks on their body image. The study found that powerlifters did not express or display any extreme perceptions of their body image despite them competing within a defined weight category. These results also find that the athletes recruited for the powerlifting group train for performance and are less concerned about their body image. By positioning their focus on objective performance (lifting as much weight as possible) this appears to have psychological benefits which helps negate negative body image as recorded in the female samples of Richardson and Chen [16] and Vargas and Winter [14]. Future research should focus on qualitative interviews with male powerlifters and additional sports to understanding the relationships between their body image and their sport.

APPLICATIONS IN SPORT
The majority of previous research concerning male body image is associated with negative behaviour outcomes such as aggression, violence and or the use of PEDs [70]. This study has taken a different approach to show strength training for males has a positive outlook on their body image helping to create healthy and stable relationships with their mental health using an objective measurement. In this instance, it is the sport of powerlifting that focuses the athletes on the performance to lift as much weight as possible across three events.

Competing in a weight class sport does not necessarily produce extreme group scores and or undesirable behaviours concerning their bodyweight or body image. This implies that strength training methods such as powerlifting for males (and females as shown in Richardson and Chen [16] when seeking to improve their health and fitness are beneficial. The focus on objective strength gains via tracking their lifting through increments using progressive overload allows positive body appreciation. As a positive by-product, they will also develop improved physique through increased levels of physical activity and adherence to a training program. Furthermore, by seeing continued progressions through improving their technical proficiency doing the movements and increased muscle hypertrophy will lead to a better outlook on their mental health and body image. As they are viewing their body for its function not as an object they place less emphasis on subjective body image changes but rather on performance. In populations that include body image disorders and eating disorders, using this form of training will help support clinicians in helping return their patients to exercise routines to support a holistic recovery pathway [71].

Author roles
Dr. Mark Chen: Conceptualization, Methodology, Formal analysis, Writing – original draft, Writing – review & editing, Supervision, Project administration.

Dr. Andrew Richardson: Conceptualization, Methodology, Formal analysis, Data curation, Writing – review & editing, Project administration.

Conflict of Interest Statement:
The authors declare that have no conflict of interest when writing and or submitting this manuscript for peer review publication to The Sport Journal.

Funding
No funding was sought or requested for the formation of this manuscript

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2024-04-22T08:06:50-05:00April 20th, 2024|General, Research, Sport Training, Sports Exercise Science|Comments Off on Male Competitive Powerlifters relationship with Body Image: Utilising the Multidimensional Body Image Self Relations Questionnaire (MBSRQ)
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Decision-making on injury prevention and rehabilitation in professional football – A coach, medical staff, and player perspective

Authors: Mads Røgen Noesgaard 1& Stig Arve Sæther2

1Department of Sociology and Political Science, Norwegian University of Science and Technology, Trondheim, Norway
2Department of Sociology and Political Science, Norwegian University of Science and Technology, Trondheim, Norway

Corresponding Author:

Stig Arve Sæther
Department of Sociology and Political Science
Norwegian University of Science and Technology, NTNU, Dragvoll, 7491 Trondheim, Norway
E-mail: stigarve@ntnu.no, https://orcid.org/0000-0002-1429-4746

Mads Røgen Noesgaard is educated as a physiotherapist and holds a master’s degree in sport science from the Norwegian University of Science and Technology. He has an extent experience as a physiotherapist from professional sports especially related to football and handball.

Stig Arve Sæther is an associate professor in sport science at the Norwegian University of Science and Technology, with an extensive research portfolio in talent development within sports and especially football. Sæther is head of the sport science staff, head of education at the department of Sociology and Political science and head of the research group Skill and Performance Development in Sports and School (SPDSS).

Decision-making on injury prevention and rehabilitation in professional football – A coach, medical staff, and player perspective

ABSTRACT

Purpose
The aim of this study is to research how the decision-making on RTP from the medical staff impact on the perceived short- and long-term performance of the player and the team, from a coach, medical staff, and player perspective. Methods: Two professional football players, one physical coach, one physiotherapist and one assistant coach were interviewed in-depth and recruited because of their insight, experience, and expertise from one Norwegian premiere league club. Results: The decision-making process on RTP in the club were partly based on the hierarchy in the club, where the coach was on the top among these actors. Despite that the actor´s describes the process as a natural dynamic, and felt a shared responsibility in the process, their different roles impact on the decisions. The RTP decision was affected by aspects such as the period in the season, earlier injury experience of the player and the medical staff and coach collaboration. Conclusions: Even though the medical staff and the injury prevention could mean that the player could have a longer career, the choices made in the process of RTP is often based on short term player and team performance. Applications in sport: Professional football players have competition as a living and are expected to enjoy and embrace competing against both other teams related to winning trophies and teammates related to a place on the team in matches. This degree of competition was also seen as a part of the RTP process since the competition with teammates gave the players motivation to overcome their injury situation and get back to compete for their “spot” on the team. Even though this study only includes experiences from one professional football club, it gives insight into how the RTP process is done in a professional football context. Future studies should consider recruiting representatives from the club management, which also could give insight on how the macro aspects of a club impact on the RTP decisions in the coaching team of a professional football club.

Keywords: return-to-play, professional sports, communication

INTRODUCTION

The development of professional football player is complex and consist of a myriad of factors, including injury prevention and rehabilitation through the return to play (RTP) (38). Even though the development of injuries in European professional football has decreased over the last two decades (10), the impact of injuries still plays a major role in both team and individual player development and success (7). Time loss in on field training and matches may have a negative impact on the players development, which makes it vital to minimize the duration of rehabilitation and RTP process. The responsibility of injury prevention, treatment and following RTP has in the literature been described as the responsibility of the medical staff, even though a strong coach and player involvement has been recommended (10). Even so, lack of needed authority in this process, have been highlighted as a challenge since both the coaching team and especially the head coach, and the players are expected to be a part of the decision process, hereby creating a dilemma (26). The need for a high performing medical team is thereby indicated crucial for the present success, but also future accomplishments (7).

Knowing that the major predictor in future injury being previous injury (13, 27-28, 35, 45), it has become standard procedure in European professional football clubs to screen and evaluate both in-squad players and potential investments even though research points to a lack of predictive capabilities (29, 46). Hereby the screening process is arguably/potentially increasing the consequences of previous injuries and treatment of such and the importance of injury preventive measures. In the pursuit of securing the best possible squad at all times injury preventive programmes such as FIFA11+, seems common but often adjusted based on either screening results or coaches’ preferences and hereby losing its evidence-based merits (29-30, 34, 46). Another promising preventive strategy is tracking and managing of load and restitution of the individual player and indicated to both increase the “here and now” short-term performance and the long-term performance. The main aim is to reduce the risk of injuries and illness (19, 24, 36), but it also presents a risk of withdrawing players from training and matches unnecessary.

The rehabilitation process of a player must address and manage the psychological and sociological health of the player (12). Though the general plan and goals of the rehabilitation is clear there is a lack of gold-standard and consensus for RTP which complicates the last steps before returning to training and competition (22). The literature advocates a shared-decision-making process to optimize this process. Coaches, medical staff, physical coaches, and the individual player all possess insight about the state of the player seen in a bio-psycho-social framework (5-6, 8, 47). A process as such is nonetheless challenged by the different profession’s confidence in their own decision, but also potentially with a lack of trust in others, hereby creating a dilemma where authority and power becomes more important than teamwork (9-10, 20). To increase the overall medical effort, the literature advocates an SDM-approach to minimize injuries and rehabilitation periods and improve RTP (1). Still, Paul et al. newly published editorial are highlighting that there has been identified concerns surrounding the social complexities of elite sports and the difficulties of truly applying this concept in practice (37).

Most of the research on this subject and in professional football have used a quantitative approach (7) and there seems to be a need of qualitative insight on how this process unfolds in practice, and how and by whom the decisions are made. An exception is Law and Bloyce (25) who interviewed professional football managers behavior towards injured players. The results indicated that managers at the lower levels felt more constrained to take certain risks related to injured players. The aim of this study is to research how the decision-making on RTP from the medical staff impact on the perceived short- and long-term performance of the player and the team, from a coach, medical staff, and player perspective.

METHODS

Participants 

Two professional football players, one physical coach, one physiotherapist and one assistant coach were interviewed in-depth and chosen based on strategic selection because of their insight, experience, and expertise in the field and their long-term involvement within one Norwegian premiere league club. The two players have in total more than 15 years in the club, while the physiotherapist and the physical coach has been in the club’s medical team for more than five years and altogether more than 20 years of experience in the field. The assistant coach has more than seven years of coaching experience. The participants are described in table 1.

 

All interviews were conducted in person and the location chosen by the interviewee. The length of each interview varied from 50 to 90 minutes with a mean at 70 minutes. Each interview was initiated with general questions to start the conversation and to get more background information on each participant. Prior to the interviews the questions were largely prepared to facilitate the conversation into different themes and topics of interest, with prepared follow up questions when depth and more context was needed. The questions varied specificity from general questions about the interviewee’s thoughts on the injury-period (e.g. “How do you think a player can develop while injured”) to more defined questions about the different actors’ actual role in the decision-making process about RTP (e.g. What role does the player has in the RTP-decisions). With these types of specific questions, the former mentioned extensive experience and expertise in the field was highly prioritized in the selection of participants. This made the insight in the specific club more extensive and gave the answers more depth. In addition, all participants were giving the opportunity to read through the transcript and afterwards able to withdraw parts or the interview in full, which none of the participants did. None of the participants neither wanted to alter the transcription. All interviews were audio-recorded and transcribed verbatim. By using pseudonyms for each participant, the transcriptions ensured the interviewee’ confidentiality and furthermore, ethical approval was in accordance with and approved by the Norwegian Social Sciences Data Services (number: 678375).          

Analysis
The analysis of data was done with the six steps of theme-centred approach as described by Braun and Clarke (2-3). The process was initiated by the transcription by the first author who afterwards read and reread the data twice. This was followed by initial coding, phase two of the chosen method. In this process the transcription was revisited multiple times until the final codes were discovered and presented to the second writer for discussion. The total of 47 codes were structed using a mind-map, which visualised the third phase of the process and used to structure the data into nine higher-order themes. Phase four was a back-and-forth process rereading the transcript, revising the raw material for clarifying questions, reviewing the codes all in all to elaborate the emerged themes. Through dialog and discussion within the research group the final three/four themes were identified, and subgroups reviewed and hereby phase five concluded. Finally, phase 6 was a detailed process and highly interwoven with the analysis of data. To present the findings in an argumentation related to research question and to illustrate the story of the data it was important to revise the extracts and go back to the both the higher order themes and the final themes in the writing of the report to ensure that the essence of the data was captured and presented. The final report presents the experienced everyday life of the participants in this specific Norwegian Premier League football club, how they perceive the decision-making process in the context of both development and performance and how the structure and reality of modern football plays and important role in both injury prevention and RTP after injury.

RESULTS

The actors in the RTP process – the club hierarchy
According to the actors (medical staff, coach and players), the prevention of injury and RTP practice has changed throughout the last decades, from a collective focus to a more specific and individual practice, described as a positive change by all the actors. RTP was described as a process, with benchmarks which was considered a motivational factor in the overall rehabilitation process. The decision-making process in the professional football club related to decisions on injured players and their capacity to play were affected to some degree by a hierarchy in the club. Even though the actor´s in the present study describes the process as a natural dynamic, and that they agree on their shared responsibility of the process, the different roles impact on the decisions.

Highest in the hierarchy are the coaches, and even though they highlight that the medical staff has an impact on their decision, the coaches seem to be the final decision maker in the process. This is indicated as a natural order because the coach is the one to take the ”fall” when the decisions shows to be wrong or more precisely have a negative output and also the final responsibility for the team performance. The coach described therefor a need to keep the medical staff on their toes, which the medical staff described as a challenge of their decisions, often based on what they considered external pressure on performance and results. This again meant that the medical staff had to make the “right” decision to keep their authority in the collaboration with the coaches.

The players felt in this regard that the medical staff had a two-sided role or responsibility both towards the coaches and the players, but that they still according to the players weigh the perspective of the player the heaviest. This double role was considered challenging and could mean lack of support in cases of doubt, while the medical staff considered that the final decision was taken by the coaches and the player. From the player perspective the trust was described as essential in this process. So even though trust, communication and collaboration are fundamental elements to keep a squad of players performing, there is also a need for a trust in the actors’ competencies and loyalty, both highlighted by the coach Lars: “Despite thinking about the result, first and foremost, we of course think: “The best for the player”. Because the player performs best when he is 100% healthy, both physically and mentally.” The physical coach Thomas stated this on the matter:

Thomas: “Because the vast majority of players understand deep down what the point is. They know when they shouldn’t go out there. They want to have hope, that: “yeah, it’s allright” and so sometimes our job is actually just to say: “Yes, it’s actually allright”, even if it’s 50/50, if it’s the last match on the season and they wanna take the chance anyways. Okay, then we have to see that and then just say: “This is allright”.

Thomas argued that their role in the process was to inform the coaches and even though the decision was not always in line with their suggestions, they felt that their opinions was considered vital for the final decision-making.

The factors that impact the decision process

Because of the complexity and uncertainty of who decides which players could play, the medical staff experience situations where at times they felt pressured to clear a player for playing, which in their experience often leads to a longer injury period. And despite the open communication, the pressure got more intense especially before important matches and at the end of the season, as this conversation and the following quotes indicates: Physiotherapist Hans: “You get a player who runs at 60%?”, Coach Lars: “Yes, but he is so important for us in set-pieces, so we have to have him”. This becomes even more prominent at the end of the season as physical coach Thomas highlights: “The fewer matches left, the greater chances you are willing to take with the athlete’s health”.

The decision to deny a player to train or play a match based on the risk of injury, was considered difficult for the medical staff because of uncertainty of the outcome. The coach describes how they in some cases start the player and see how it goes. Even though this was described as happening seldom and especially since this could be considered treating the players differently, which potentially could impact the team dynamic:

Lars: “If you and I play in the same position, and you train 3 times a week but you are a little better than me. I’m training every single day, and then you get to play matches. I train more than you, twice a week, and then arrangements will be made for you to play. That could become a conflict.”

The medical staff points out how this load-management strategy is potentially positive for RTP, the coach argument furthermore how this might add pressure for the next matches both for the player and the medical staff. If the team loses, one could consider that being in minus and that means that the next match must be won. This adds on to the earlier statement that an injury might be a heavy process for a player:

David: “From the moment you feel that you are a part of something, then you will show up the day after you have been injured, then you show up for work. You eat breakfast, you go to the locker room and then the rest of the team go out on field and do what you love the most, they play football. But you wander into a dark gym alone and do what all footballers think is the most boring job, cycling and doing rehab training. As boring as it gets. But you have to do it. You go into such a lonely and confined, empty mental phase, it’s really hard.”

What was considered the “right” decision depended on the perspective, even though obviously the most impacted part is the player:

Niels: “Perhaps I have been lucky in that I have not had so many major injuries, but at the same time the one injury I have had, where it was done the way it was done, that was enough for me to think: “yes, I lost some good matches that year”, then you can think of those who have been injured longer and have had more injuries, how much it has affected them.”

Injuries are however also described by all actors as a natural part of professional football, and that this often means taking risks to be able to perform on the highest level. One of the players, David, describes it as following:

David: “At the top level, you are balancing on a knife’s edge much more often, because you are pushing boundaries all the time and then the need for medical help is all the greater than when you operate at a not so fully professional level.”

It could seem from a professional players perspective that the players consider their everyday life as a footballer as finding the optimal balance to be able to stay fit and avoid injuries, and that this situation is difficult and that they need help from the medical staff to be able to keep staying “in the game”. Even so, the physical coach Lars highlights the difference between pain and injury:

Lars: “I think when you play football and it’s one-on-one, it’s dueling, you can get a knee in the side, you can get hit by an elbow, so after a football match, you might have a bruise here and a little bit of swelling there and you can have, stiffness in generel. That doesn’t mean you need 2-3 days to recover because that pain you feel”.

Protecting the players

The coach stated that it was important to protect the players and not introduce them for unnecessary risk, even though he pointed out that there is a limit in terms of how much consideration one could do for each player. In this regard did the physical coach acknowledges that there had not been a reduction in the number of injuries despite the heavy number of added resources to prevent them. The injuries have changed but one has not been able to eliminate the incident rate:

Thomas: “There is much less ankel rolls, but there are more hamstring injuries and groin injuries because there is more sprinting in the matches and the matches are closer schedueled. And you can’t quite solve that. Even with sufficient sleep, enough nutrition, tablets in the fusion of plasma, i.e. “you name it”, game ready – the player still breaks down and then you see that if you train very well, then maybe you will go through the season with very little damage.”

This was also something the players describes as problematic in certain situations, as stated by Niels: “Coach, physio and they, they really push you back in and then it’s difficult as a player to sit there and say: “I’m not healthy”, it’s difficult!”

The physical coach recons it is all about the time spent on the pitch to improve RTP and the high amount of matches impact on the possibilities for the medical staff to schedule and complete the injury preventions and rehabilitation. One example mentioned are an away match where the travel time is the reason for the player not attending enough training sessions, even though he is ready to train.  Furthermore, the game importance is an important factor because of the impact on the results sportingly and economically and has been found to be the reason as to why players play partly injured, or at least adding on to the pressure on the medical staff and their decision on every player potentially injured.

          Also, one of the players described how he perceived that the players are at their best when the get to train and play matches as much as possible:

David: “All footballers perform at their best when they get the opportunity to play football every day. Play every match. That’s when you get into a rhythm, where you act on intuition in battle and in that moment. In order to do that, you have to have continuity in your training and to have that, you have to be good at taking care of your body, to manage and last through a tough week of training, to perform in every match. So it’s definitely important. You profit from doing a good job (ed. injury prevention) in order to be able to perform in the best possible way. It is absolutely indisputable.”

Both the players and the medical staff highlights that the injury prevention is important for the players to be able to train more.  The physical coach highlights that this injury prevention training has a direct impact on the player opportunity to run faster and develop more power.

One of the players mentions how each club and their culture try to maximise the development and that the club culture is impacting the performance. This was also mentioned by the coach who stated that building the club is one of the most important tasks for the club, which is considered difficult since both players and coaches comes and goes. Another challenge is the impact the head coaches have on how the club perceive injury and development. The physiotherapist describes how the many changes also impact on the medical staff and their way of working:

Hans: “I think that, the biggest challenge in all of this is the constant change in player material, the constant change, at least as it has been in X, that coaches change, and therefore you constantly have different routines. It is natural that a coach who comes in and is boss wants to have it his way, and then a new coach comes in who wants it his way. Then there will always be changes and that means that what you tested on last year will be tested in a different way this year.”

Both players and the physical coach add on to this position, even though they also see positive outputs when new people are trying to collaborate:

Thomas: “Things that work well can also be diluted by poor execution. I think we make it work. I think so. that’s how it is when you bring new things to the table. Basically, it should be a good thing and if you manage to get best out of it, then it will be beneficial.”

The injury situation as an opportunity for development

All the actors thought of the injury period as a period for potential development of performance level of the player. So even though the players considered it as a tough and challenging period, it also contains opportunities. The coach highlighted that this motivation and opportunity had to come from within, and that he medical staff and the coach’s role was to facilitate and further motivate. In that way the injury period can be effective and also an opportunity, which could be considered a win-win situation both for the player and the team. 

Still, at times the players felt pressured to play, and sometimes felt alone and “naked” in the discussion between them, the medical staff and the coaches. This was partly confirmed by the physiotherapist, who described football as being black or white at times, and that he felt the need to protect the player:

Hans: “A player who is out several times and often… It can very quickly become black and white in a football club, “This player is always injured. No, we’ll give up on him a little”, and then it’s challenging to say: “You mustn’t give up on him, even if he’s a bit injured now. There are several factors that cause him to be injured and we have to look at ourselves as well, all of us.” What we have often done is to look at the coach and say: “If we are going to get him out of this, we’ll have to make a change. What we are doing now is not good enough. So we have to take him out of training and have to do this instead of that. He can’t play every game and at the moment”.

However, at other times the medical staff also feel the need to push the players to return to ordinary training or playing matches. They feel the need to be careful since they might misstep. Some players might get pushed back to soon, while others need a push.

Lars: “Sometimes where you have to push a little, and we really do that for the sake of the player, not because we absolutely have to. We don’t take any chances with players, that is. But if we see that he has done what he is supposed to and at the same time it is a player who is a bit more careful with himself. Because that too, you have to know the group, you have to know the player, because there are some who can be too tough too early, and then there are some who are actually ready, but holding back. So you can say that sometimes we have to try and push them in a positive way too, I think. Without us doing anything wrong.”

One of the players Niels stated that for some of the players, they need to be more included in the decision-making-process. One example mentioned by one of the players was the importance to get into the pre-season together with the squad, to be able to compete about his playing position.

The medical staff clearly stated that they did not consider themselves having the definitive solution in every case. They also mentioned the fact that holding a player back from a match based on the fear of being injured might deprive the player from development and potentially economic gain (e.g. club transfer, bonuses etc.) or the team’s performance or the club’s economic gains. Many of the actors highlighted that if the player felt ready to play, and the coaches meant that he would have an impact on the game, the medical staff would take that into consideration. This position of taking a decision which is good for all the actors both in a short-term and long-term perspective was considered a difficult dilemma for the medical staff, since they feel an extra responsibility related to the players health.

Keeping the players on their toes but still together

The coach also highlighted that the competition between players could challenge the individuals in the club. Internal competition is essential and when a player is injured, that could create an opportunity for other players. This competition was also highlighted by the two players, however as a stressor for the injured player. The coach however stated that this type of competition must be present and that it makes the players push each other, and fight for a place on the team. This type of pressure, trying to withhold your place on the team, having the right attitudes, frequent changes in the coaching staff, and short-term results, was describes from all the actors as impacting the medical staff’s opportunity to impact the decision for players to play matches and their development. Both the coach and the medical staff highlighted that this might impact the decision, but never determined the RTP, while the players could consider this as a weighty stressor

The players point out a potential isolation of the injured players by dividing the players into two groups: those who are injured and those who are not, but this division is described differently based on the perspective. They also describe the rehabilitation as lonely, heavy, and boring, especially the acute phase, and experience that the injured players not to be a part of the community in the club, which the player Niels described in the following: “But I want to put it this way, you are down in hell and then you start the ascent from there, and then it becomes a bit like tunnel vision. You don’t see the light at the start, but you see it eventually”. The coach, however, does not describe this as an isolation or division of the team, but rather a natural part of the everyday life in a club, but highlight the importance of joint meals and meeting schedules. The medical staff have another nuance of this division, since an injury might be challenging and create a sense of exclusion, while this could also be good for the team, since the negativity which often comes with an injury does not get spread among the other team members. The physical coach highlights the same and furthermore that it should be attractive not to be injured.

All the actors describe the deprivation from matches in times of doubt about a player’s availability have both sportingly and economic negative impact on the player’s career:

David: “Football can be so simpel that if you, how should I put it , score a hat-trick in the right match against the right team, you can be like… And the salaries are so high, so if you end up in the right place then you, then you can in a way support the whole family for the rest of your life. So it’s quite clear that injuries affect the course of a career.”

Injuries means less time to train, and the actors agree that the time for the specific football training and matches are essential for a player’s individual development. Both the coach and the physiotherapist highlighted however the importance of making the most of the injury period, which could be considered as a window of opportunity to focus on individual skill development, which normally one does not have time for. The physical coach stated however that it might be difficult for a player to develop largely during the rehabilitation process. And this could be related to the somewhat black-white perspective the medical staff and the coach has on injuries. The physiotherapist meant that this approach might have a positive consequence for a player who have experienced an injury. They often work harder than before to be able to get back to football. At the same time Hans also pointed to the fact that the players could be “forgotten” by the coaches if they achieve a “bad” reputation: “But if you first get a reputation of being.. that the coach gets the feeling that he is not available, then it can often be difficult. A fight really. That is my experience”. The coach Lars partly confirmed this by stating that the coaches are aware of players who have a history of injuries, which often mean that they cannot play all matches during a season:

Lars: “In other words, injury follows injury. It’s a bit like that. So there are certain players that you know more or less that he is not going to play 100% of the games. Let’s say there is an exclusive player who often gets hamstring issues, then you know that during the season he will play 70% of the games. It may happen that we have players, who we know are like that.”

In a long-term perspective and focusing on the players career, the coach also highlighted that the players are screened and assessed by clubs if a club transfer is in motion, that a player with a large injury history would be considered as less interesting to recruit:

Lars: “[…] But the more players who don’t have an injury history.. So if you’re going to build a team then you have to get as few players as possible with an injury history, because often you see that those type of issues, especially if it’s the groin or hamstring or those types of injuries, they often come back.”

The coach described players’ injury history as essential when clubs assess which player they could recruit, and that injured players must convince the coaches to become relevant for a club transfer. These types of assessment are important for coaches in their process of building a squad both in a short-term and long-term perspective.

Discussion

The aim of this study is to research how the decision-making on RTP from the medical staff impact on the perceived short- and long-term performance of the player and the team, from a coach, medical staff, and player perspective. The decision-making process on RTP in this professional football club were partly based on the hierarchy in the club (40). So, despite that the actor´s in the present study describes the process as a natural dynamic, and felt a shared responsibility in the process, their different roles impact on the decisions. The coaches were described highest in the hierarchy and related to them being responsible for the sportingly results and the performance of the team. The players were described as having a say in the decision of his availability, even though they often highlighted an experience of being pressured to play in certain situations (9). The medical staff was considered to have a two-sided role, since they were employed and a part of the coaching team and naturally felt a responsibility on behalf of the coaches and the club, they also felt the need to protect the players and their health as professional health workers (20). Their decisions would often mean that they had to “disappoint” the coaches or the player, by denying the player to play or the availability of a player in a match.

Responsibility was a term especially the medical staff used to describe how they felt about their role, but also when taking part in the final decision in the RTP process. This responsibility became important in the process of making “the right” call based on the information available while trying to account for the interests of all the actors. This might mean that they let a player play, with a “let´s see how it goes” approach, and that the outcome of the decision was described as “right” if the player played the whole game. A dilemma in the process was also related to the natural part of pain and injury as part of professional football described by all the actors in the process (31). So even if protecting the players was important, time spent on the pitch is the main goal for both the individual players and the team’s development and performance. Even so, earlier research (41) has indicated that elite sports have a pain culture where pain is a natural and expected part of elite sports, which could have a negative impact on the players development, if this means that the players do not communicate when feeling injured or unavailable for training and matches.

Professional football is all about results and performance (32). So, a characteristic off successful environments is their constant search of areas to develop further (14). This seemed to be the case in this club as well since a period of injury was considered an opportunity for the player to develop. The players are competing about a place in the starting line-up and need to pick up the glow to get back into the team. Still, there was also a mutual understanding that each RTP case might be different and had to be considered individually. So, in some cases both the medical staff and the coaches felt that some players needed a push to get back. This may in many cases also be in the best interest of the player since it could mean that they in example get identified by scouts, impacting their career by a club transfer. Furthermore, this pressure could mean that the players are willing to take a higher risk by playing while injured. The players in this study described being injured as lonely and feeling isolated from the team, as found in earlier studies (32), which could be perceived as an increased motivation to RTP potentially even before the mind or body are ready.

In accordance with the focus on results and performance in professional football are also the high degree of uncertainty in this professional context (15). This could be related to the small margins between success and failure. This is also related to the RTP process, since all actors in the process of RTP must make the best decision for both the individual and teams’ performance. Still, there is a lack of knowledge related to the potential outcome of the decision. This means that the actors must “take risks” to be able to maximize the opportunity to succeed. While it was not a part of the study, the obvious economically benefits of decreasing time loss in training and competition on both an individually (players, medical team, and coaching team) and club level (potential sale of players), also makes both the rehabilitation and preventive strategies important. The club perspective might conflict with the individual actors in the RTP process, with the example of the club winning the league, while a player got injured because of the overload and hereby potentially ending his career.

CONCLUSIONS

All the actors in this study highlight that football is a sport where you must expect to feel pain regularly and that injury is a part of being a professional football player. So even though the medical staff and the injury prevention could mean that the player could have a longer career, the choices made in the process of RTP is often based on short term player and team performance. Professional football players have competition as a living and are expected to enjoy and embrace competing against both other teams related to winning trophies and teammates related to a place on the team in matches. This degree of competition was also seen as a part of the RTP process since the competition with teammates gave the players motivation to overcome their injury situation and get back to compete for their “spot” on the team. Even though this study only includes experiences from one professional football club, it gives insight into howe the RTP process is done in a professional football context. Future studies should consider recruiting representatives from the club management, which also could give insight on how the macro aspects of a club impact on the RTP decisions in the coaching team of a professional football club.

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2024-04-08T09:47:11-05:00April 8th, 2024|General, Research, Sports Management|Comments Off on Decision-making on injury prevention and rehabilitation in professional football – A coach, medical staff, and player perspective
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Comparing Public vs. Private High School Sports-Related Concussions from a Countywide Concussion Injury Surveillance System

Authors: Gillian Hotz1, Jacob R. Griffin2, Hengyi Ke3, Raymond Crittenden IV4, Abraham Chileuitt5

1Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL, USA
2KiDZ Neuroscience Center, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, USA
3Department of Public Health, Division of Biostatistics, University of Miami Miller School of Medicine, Miami, FL, USA
4Department of Neurology, University of Miami Miller School of Medicine, Miami, FL

Corresponding Author:

Gillian Hotz, Ph.D.
1095 NW 14th Ter
Miami, FL 33136
ghotz@med.miami.edu
305-243-2074

Gillian A. Hotz, PhD is a research professor at the University of Miami Miller School of Medicine and a nationally recognized behavioral neuroscientist and expert in pediatric and adult neurotrauma, concussion management, and neurorehabilitation. Dr. Hotz is the director of the KiDZ Neuroscience Center, WalkSafe, and BikeSafe programs.

Comparing Public vs. Private High School Sports-Related Concussions from a Countywide Concussion Injury Surveillance System

ABSTRACT

Purpose
Largely, research on adolescent sports-related concussion (SRC) has focused on public school athletes. SRCs of private school athletes have been studied less and may differ due to differences between school types.

Methods
SRCs between Miami-Dade County high school athletes at trained public (n = 1088), trained private (n = 272), and untrained private (n = 79) were compared. Outcomes included days between date of injury (DOI) and clinic date, days between DOI and post-injury ImPACT retest, days withheld, return to play (RTP), ImPACT baseline and post-injury retest completion, and academic accommodation status.

Results
Trained public and trained private groups had similar days between DOI and clinic date, days withheld, and percentage who RTP. Differences between the trained public and untrained private groups existed for RTP but not for days between DOI and clinic date or days withheld. Private group athletes were more likely to receive academic accommodations.

Conclusions
Public and private high schools trained on the same SRC protocol did not have significantly different outcomes. The untrained private schools, however, had worse outcomes compared to the public group.

Application In Sports
SRC outcomes in both public and private high schools may benefit from SRC education, training, an established protocol, and use of a management system.

Keywords: youth athletes, concussion recognition, concussion management, private schools, sports

INTRODUCTION

Each year, an estimated 1.6 to 3.8 million sports-related concussions (SRCs) occur in the United States (1). While the nearly 8 million high school athletes participating in sports annually benefit from the improved social, psychological, and physical health gained from playing sports (2, 3), there is also an ongoing risk of injury due to consistent athlete-exposure (4). SRCs are understandably a concern for high school aged athletes due to the short-term and potentially lifelong behavioral, cognitive, emotional, physical, and psychological effects they can produce (1, 5). These consequences can be particularly worrisome as this population is already experiencing their own ongoing physical and cognitive development changes that can negatively be affected by an SRC (6). Understanding risk factors contributing to adolescent SRCs and what may lead to differences in outcomes is therefore imperative for identifying those most at risk and ensuring the proper management and treatment resources are in place.

Thus far, an overwhelming majority of research on SRCs has focused on or included samples of public high school athletes as opposed to private high school athletes. One example is the High School Sports-Related Injury Surveillance Study, Reporting Information Online (RIO) (7). The High School RIO is an internet-based data collection tool that captures athletic exposures and injury events through athletic trainers (ATs) that report data. It is often used as a source of SRC data for research (4). In the most recent report, nearly 80% of the participating high schools were public with the rest being private (7). Additionally, other studies on SRC incidence and trends have included only athletes from public high schools (8.) The lack of private high school inclusion in adolescent SRC research is an important consideration because known distinctions between public and private high schools possibly lead to differences in SRC incidence and outcomes (4). These include differences in school size, support services and resources, student racial/ethnic backgrounds, rigorous academic programs, and socioeconomics (9).

While there has been recent research that details private high school athlete SRC experiences and reporting behavior (4, 10), there is still a need for continued research into private high school SRC outcomes. Specifically, it would be important to examine how SRC outcomes differ between public and private high schools. Therefore, the purpose of this study was to compare SRC outcomes between public high schools who received specific concussion training and education to private high schools who received the same training and private high schools who did not receive training on the same SRC protocol. The goal of using these three distinct groups was to examine whether differences in SRC outcomes would be a result of differences in SRC education, training, and protocol.

METHODS

Participants and Procedures

This study included Miami-Dade County (MDC) public and private high school athletes with an SRC that occurred in a practice or game between August 1st, 2012, and July 31st, 2022. All athletes were treated at the University of Miami Miller School of Medicine’s Concussion Clinic, UConcussion (UCC). Athletes that sustained an SRC outside of the study period were excluded as well as those with an SRC that did not occur during an MDC public or private high school practice or competition. If an athlete was treated at a provider other than the UCC, they were also excluded. 

 The UCC clinical team hosts an annual SRC training and educational workshop for MDC public high school ATs and athletic directors (ADs). In these workshops, ATs and ADs are trained on how to use the Six Steps to Play Safe protocol (11) and how to administer ImPACT (12) concussion tests. The UCC also makes available specialty concussion clinics where athletes with a suspected SRC can be referred to for management and treatment. The UCC similarly partners with and provides training and education to 8 private high schools within MDC. While athletes at other private high schools within MDC can still be referred to and receive treatment at the UCC, ATs and ADs at these high schools are not provided with the same educational workshops and training on the Six Steps to Play Safe protocol (11). In this study, there were 35 trained public, 8 trained private, and 29 untrained private high schools that were grouped as either “trained public,” “trained private,” or “untrained private,” respectively.              

The Six Steps to Play Safe (11) is a standardized protocol that can be used to manage an athlete’s SRC and safe return to play (RTP) and return to school during recovery (Figure 1). Included in this protocol are, in order, pre-season ImPACT (12) baseline testing, AT sideline testing, post-injury ImPACT testing, SRC clinic follow-up, gradual RTP and return to learn protocols, and SRC injury surveillance form completion.

Variables
Reported variables were collected during UCC visits and from surveillance reporting by ATs. Athlete information in the study included demographics and the sport played when the injury occurred. SRC specific information was also reported and included date of injury (DOI), days between DOI and first clinic date, days between DOI and post-injury ImPACT retest, RTP status (yes/no), and days between DOI and RTP (days withheld). To eliminate the few extreme outliers, athletes were only included in days between DOI and first clinic date as well as days withheld mean calculations if the value for these variables was < 120 days. For similar reasons, only athletes with days between DOI and post-injury ImPACT retest < 30 days were included in the calculation. Whether an athlete received academic accommodations was included as a variable because previous research (13) suggests that private high school students experience particularly high levels of stress due to concerns about academic performance and school requests, which potentially impacts whether academic accommodations are prescribed. The percentage of athletes who experienced loss of consciousness (LOC) was also reported because LOC indicates a potentially more severe SRC and is associated with longer recovery than SRCs without LOC (14). Athlete ImPACT (12) baseline testing and post-injury data from the ImPACT test online database was included and used to determine whether athletes had completed a baseline ImPACT test and/or a post-injury ImPACT retest. ImPACT testing comparisons were only included for the trained public and trained private high schools since untrained private high schools either did not use ImPACT or did not grant the UCC access to their records.

Data Analysis
Data analysis was performed using R 4.2.2. Athletes sustaining an SRC from MDC public high schools were compared with athletes from private schools between 2012-2022. The eight private schools were particularly selected because they followed a similar protocol and received the same SRC education as the public schools. The other 29 private schools did not receive the training or follow the protocol. For continuous data in the normal distribution like “Age”, mean and standard deviation were reported. For categorical data, such as “Gender”, data was presented as frequency and percentage. For those variables with important clinical significance, such as “Days withheld”, data was reported as median and interquartile range. Propensity score matching was performed to match the public schools with the eight private schools who received similar SRC training. SRC outcomes were therefore compared between trained public and trained private schools before and after matching. This was done to confirm whether one hypothesis, that public and private schools trained on the same SRC protocol would not differ in SRC outcomes, would be true when baseline covariates were and were not controlled for between the groups. Sample T-test was used to detect the significant difference for quantitative data in the normal distribution. The Wilcoxon test was used for quantitative data in non-normal distribution. The Chi-Square test was used to detect significant differences in categorical data. Statistical significance was set at < 0.05.

RESULTS

Participant Demographics
A total of 1,088 public, 272 trained private, and 79 untrained private athletes were treated at the UCC during the study period and are included in this study. The average age was similar for each group (16.5 and 16.2). While there were more male than female athletes in all three groups, the percentage of athletes that were female was greater in the trained (38.6%) and untrained (38.0%) private groups than the public group (25.9%). In both the trained and untrained private groups, a greater percentage of athletes were White (28.5% and 25.3%) or Hispanic (62.6% and 68.0%) compared to public athletes (8.0% White, 56.4% Hispanic). The public group instead had a greater percentage of Black athletes (30.9%) than the trained (24.7%) and untrained (6.7%) private groups. Across all three groups, football accounted for the greatest percentage of SRCs but was more prevalent in the public (58.3%) than both private groups (36.4% and 39.2%) (Table 1).

Comparing Trained Public and Trained Private High Schools SRCs
Data from trained public and trained private high schools was compared to determine if there were any differences in outcomes between public and private high schools that were trained using the same protocol and program. There were no differences between the groups for days between DOI and first clinic date (P = 0.1), days withheld (P = 0.83), post-injury retest completion (P = 0.06), and RTP (P = 0.30). The average days between DOI and post-injury ImPACT retesting was smaller (P < 0.001) for the public (3 days) than trained private (6 days) group. The public group also had a greater percentage of athletes who completed ImPACT baseline testing (88.5% vs. 80.1%; P < 0.001). The trained private group had a significantly greater percentage of athletes who had academic accommodations (P < 0.001) and experienced LOC (P < 0.001) (Table 2).

After matching, groups had similar demographic characteristics for age, sex, race, grade, and sport (Table 3). Outcomes between the matched groups were also compared, and there were no differences for days between DOI and first clinic date, days withheld, percentage of athletes who completed ImPACT baseline testing and post-injury retesting, and RTP (Table 4). However, average days between DOI and post-injury ImPACT retest was smaller for the public group (4 vs. 6 days, P < 0.001). The public-school group was also more likely to have experienced LOC (P < 0.001) and not receive academic accommodations (P < 0.001).

Comparing Trained Public and Untrained Private High School SRCs
Trained public and untrained private groups did not differ in average days between DOI and first clinic date (P = 0.40) or days withheld (P = 0.40). A significantly greater percentage of the public group did RTP (91.9% vs. 81.0%; P = 0.002). More of the athletes in the untrained private group received academic accommodations (P < 0.001) and experienced LOC (P < 0.001) than did the trained public group (Table 5).

Discussion

Understanding risk factors, whether demographical (e.g., sex, age) or injury event-related (e.g., sport, mechanism of injury), that are associated with differences in SRC outcomes are important for ensuring that those most at risk receive proper SRC treatment and resources. One potential risk factor that was explored in this study was whether an athlete was from a public or private high school. Historically, most research on SRC risk and outcomes has been conducted using public high school athletes (4). This study provides further insight into how SRC outcomes between high school athletes differ based on the type of school attended and if a dedicated SRC protocol and education can help mitigate any differences.

While football accounted for the greatest percentage of SRCs in all three groups, its contribution was roughly 20% percent more in the public group than both private groups. Other sports, including soccer, basketball, and volleyball, were more prevalent in both private school groups. The distribution of sport played during the SRC injury event likely differed between public and private groups because private schools offer a variety of sport options, like crew and sailing, that were not available at public schools. This availability may have impacted the popularity of sports and participation numbers as private school athletes had a greater number of sports to choose from.

To our knowledge, there is only one other study (15) that directly compares SRC experiences between public and private schools. In that study, private school athletes were twice as likely to report a history of SRC compared to public school athletes, but there was no difference in RTP timelines between athletes at the different types of school (15). While the current study did not compare history of SRC between school types, analysis was performed to compare rates of RTP. There was no significant difference between the trained public and trained private school groups for RTP percentage or days withheld (Table 2), similar to the other study that concluded no difference in RTP. After matching, there was still no difference in RTP percentage or days withheld between these groups (Table 4). The untrained private group, however, had significantly less athletes RTP than the trained public group (Table 5). The UCC is a specialized concussion program that provides comprehensive SRC management and treatment, but the program also provides continuing education and a standardized protocol to the trained public and private high schools to better identify, manage, and treat athletes with an SRC (11). Athletes at these participating trained high schools potentially benefited from the coordinated and structured care they receive as a result of these trainings and partnerships, which may have led to better RTP outcomes compared to the untrained private group. These results also suggest that SRC outcomes do not necessarily depend on school type and the systematic differences between public and private schools (4, 9), but instead on AT and AD SRC education and if an SRC protocol is in place and being followed. Additionally, these results also indicate the positive effect an available and established SRC program and protocol with clinicians trained on SRC management and treatment can have on SRC outcomes.
Another finding was that the trained public and untrained private groups did not differ in average days between DOI and first clinic date (Table 5). Systematic differences in socioeconomics between public and private high schools (9) may explain why the trained public group did not have significantly fewer average days between DOI and first clinic date than the untrained private group, which was the initial hypothesized result. There is well established evidence (16) that supports a relationship between socioeconomics and access to healthcare, and socioeconomic differences between school type may have led to barriers, including transportation, time, and costs, that delayed public athletes from getting into the UCC (17). Yet, there was also no difference between trained public and trained private groups for average days between DOI and first clinic date in both unmatched and matched comparisons (Tables 2 and 4), suggesting that UCC’s partnership with these schools and the flexibility it provides by offering both on-site and virtual appointments may have alleviated any potential differences. These findings also indicate that educating ATs and ADs on the risks of SRCs leads to quicker identification and subsequent appointments.

The percentage of athletes who received academic accommodations after an SRC was significantly greater for both the trained (unmatched and matched) and untrained private school groups compared to the trained public school group. During recovery from an SRC, athletes may have post SRC symptoms that can interfere with their ability to participate and function in the classroom setting (18). Consequently, return to learn protocols and academic accommodations are often provided to the athlete to help reintegrate them into classes but also prevent worsening symptoms (19, 20). Previous research (13) shows that private school students face a particularly high level of academic pressure, potentially due to more rigorous academic programs (9), which could explain why a greater percentage of private groups in this study received more academic accommodations. These additional academic accommodations may have been provided to reduce the burden private group athletes felt about their academic responsibilities or at the request of academic advisors employed at these schools. However, it is important to ensure that all athletes with a sustained SRC receive any appropriate and necessary academic accommodation, regardless of school type attended, to prevent further symptom development.

Limitations
This study is not without limitations. All participants in this study were athletes that attended a public or private high school in MDC. Results may not be generalizable to other playing levels, like youth, middle schools, and college, nor to public or private high schools in other counties. Additionally, while other counties may have their own SRC surveillance system, they may not have a program, such as the UConcussion program, that provides ATs with additional SRC training and encourages timely, accurate reporting. A larger sample population in all three groups would have also been beneficial and provided more evidence on the impact of SRC education and protocol on SRC outcomes in the high school setting.

CONCLUSIONS

Public and private high school groups trained on the same SRC protocol did not have significantly different SRC outcomes. The untrained private high school group, however, had worse SRC outcomes compared to the public school group, suggesting that SRC outcomes in the high school setting may benefit from education, training, and an established SRC protocol and program and not on whether the school is public or private.

Applications In Sport

An inherent risk of playing sports is injuries, and SRCs are a particularly concerning injury for high school athletes, especially those playing contact sports. Ensuring those responsible for helping to manage SRCs in high schools are educated about SRCs is important, and a collaborative approach to treating and managing SRCs has been recommended (20). As suggested by this study, all high school personnel involved with athletics should be offered SRC management training and education to help improve outcomes of those that sustain an SRC. Additionally, an SRC protocol, like the Six Steps to Play Safe (11), should be established and can include:

  • Pre-season baseline testing, using computer-based tests such as ImPACT (12)
  • Sideline testing after a potential SRC injury (SCAT5, Balance Error Scoring System (BESS), etc.)
  • Post-testing after a suspected SRC (to compare neurocognitive scores to pre-season baseline tests)
  • Clinic appointments with a healthcare professional trained in SRC who can evaluate tests and make recommendations
  • Gradual RTP and return to learn protocol after the athlete has been examined by a professional and is asymptomatic
  • Injury surveillance system reporting by ATs

ACKNOWLEDGEMENTS
The authors would like to thank: Dr. Kaplan and the UHealth Sports Medicine Clinic and Staff, the Division of Athletics and Activities for the Miami-Dade County Public Schools, all Miami-Dade County High School Certified Athletic Trainers, previous UConcussion team members, Dr Kester Nedd who served as medical director of the program from 2012 to 2019, current medical director Dr. Abraham Chileuitt, and The Miami Dolphin Foundation for supporting countywide ImPACT testing and educational workshops. We also want to thank David Goldstein and the Goldstein Family for the development of the Countywide Concussion Care Program and their initial and continued support. The project was supported by the University of Miami Clinical and Translational Science Institute.

REFERENCES

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  5. Tator, C. H. (2013). Concussions and their consequences: Current diagnosis, management and prevention. Canadian Medical Association Journal (CMAJ), 185(11), 975-979. 10.1503/cmaj.120039
  6. Daneshvar, D. H., MA, Riley, D. O., SB, Nowinski, C. J., AB, McKee, A. C., MD, Stern, R. A., PhD, & Cantu, R. C., MD. (2011). Long-term consequences: Effects on normal development profile after concussion. Physical Medicine and Rehabilitation Clinics of North America, 22(4), 683-700. 10.1016/j.pmr.2011.08.009
  7. Injury & amp; violence prevention center (IVPC). University of Colorado Denver | Anschutz Medical Campus. Accessed June 9, 2023. https://coloradosph.cuanschutz.edu/research-and-practice/centers-programs/ivpc/research-practice/research-projects#ac-rio-study-reports-1.
  8. Lincoln, A. E., Caswell, S. V., Almquist, J. L., Dunn, R. E., Norris, J. B., & Hinton, R. Y. (2011). Trends in concussion incidence in high school sports. The American Journal of Sports Medicine, 39(5), 958-963. 10.1177/0363546510392326
  9. Choy SP. Public and Private Schools: How Do They Differ? National Center for Education Statistics, U.S. Dept. of Education, Office of Educational Research and Improvement; 1997.
  10. Waltzman, D., Daugherty, J., Snedaker, K., Bouton, J., & Wang, D. (2020). Concussion reporting, return to learn, and return to play experiences in a sample of private preparatory high school students. Brain Injury, 34(9), 1193-1201. 10.1080/02699052.2020.1793388
  11. Lopez AD, Schnayder M, Pomares B, Siegel J, Nedd K, Hotz G. Academic Accommodations for a Countywide Concussion High School Program. The Sport Journal. 2017.
  12. Impact concussion test: Impact applications. ImPACT Concussion. January 3, 2023. Accessed June 9, 2023. https://impactconcussion.com/.
  13. Leonard, N. R., Gwadz, M. V., Ritchie, A., Linick, J. L., Cleland, C. M., Elliott, L., & Grethel, M. (2015). A multi-method exploratory study of stress, coping, and substance use among high school youth in private schools. Frontiers in Psychology, 6, 1028. 10.3389/fpsyg.2015.01028
  14. Kelly, J. P. (2001). Loss of consciousness: Pathophysiology and implications in grading and safe return to play. Journal of Athletic Training, 36(3), 249-252. https://www.ncbi.nlm.nih.gov/pubmed/12937492
  15. Post, E. G., Snedden, T. R., Snedaker, K., Bouton, J., & Wang, D. (2021). Differences in sport-related concussion history, reporting behavior, and return to learn and sport timelines in public versus private high school student athletes. Brain Injury, 35(5), 596-603. 10.1080/02699052.2021.1890217
  16. McMaughan, D. J., Oloruntoba, O., & Smith, M. L. (2020). Socioeconomic status and access to healthcare: Interrelated drivers for healthy aging. Frontiers in Public Health, 8, 231. 10.3389/fpubh.2020.00231
  17. Love, H., Panchal, N., Schlitt, J., Behr, C., & Soleimanpour, S. (2019). The use of telehealth in school-based health centers. Global Pediatric Health, 6, 2333794-2333794X19884194. 10.1177/2333794X19884194
  18. McGrath, N. (2010). Supporting the student-athlete’s return to the classroom after a sport-related concussion. Journal of Athletic Training, 45(5), 492-498. 10.4085/1062-6050-45.5.492
  19. Carson, J. D., Lawrence, D. W., Kraft, S. A., Garel, A., Snow, C. L., Chatterjee, A., Libfeld, P., MacKenzie, H. M., Thornton, J. S., Moineddin, R., & Frémont, P. (2014). Premature return to play and return to learn after a sport-related concussion: Physician’s chart review. Canadian Family Physician, 60(6), e310, e312-e310. https://www.ncbi.nlm.nih.gov/pubmed/24925965
  20. McCrory, P., Meeuwisse, W., Dvořák, J., Aubry, M., Bailes, J., Broglio, S., Cantu, R. C., Cassidy, D., Echemendia, R. J., Castellani, R. J., Davis, G. A., Ellenbogen, R., Emery, C., Engebretsen, L., Feddermann-Demont, N., Giza, C. C., Guskiewicz, K. M., Herring, S., Iverson, G. L., . . . Vos, P. E. (2017). Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in berlin, october 2016. British Journal of Sports Medicine, 51(11), 838-847. 10.1136/bjsports-2017-097699
2024-03-18T11:04:24-05:00April 5th, 2024|General, Research, Sport Training|Comments Off on Comparing Public vs. Private High School Sports-Related Concussions from a Countywide Concussion Injury Surveillance System
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An analysis of the factors impacting win percentage and change in win percentage in women’s Division 1 college lacrosse

Authors: Christiana E. Hilmer1

1Department of Economics, San Diego State University, San Diego, CA

Corresponding Author:

Christiana Hilmer, PhD
5500 Campanile Drive
San Diego, CA 92182-4485
chilmer@sdsu.edu
619-301-9388

Christiana E. Hilmer, PhD, is a Professor of Economics at San Diego State University in San Diego, CA. Her research interests include the economics of sports, applied econometrics, labor economics, and resource and environmental economics.

An analysis of the factors impacting win percentage and change in win percentage in women’s Division 1 college lacrosse

ABSTRACT

What factors in women’s NCAA Division 1 college lacrosse led to an increase in win percentage in a single season and a change in win percentage across two consecutive seasons? Do these factors differ between teams at the top and the bottom ends of the win distributions? Using data from the 2023 and 2022 lacrosse seasons, we find that goals, assists, unassisted goals, and participation in the NCAA Championship tournament have a positive impact on win percentage, while opponent’s goals and if the team was new in 2023 have a negative impact on win percentage. The most crucial factor that explains the change in win percentage between the 2022 and 2023 lacrosse seasons is an improvement in the change in total shots ratio, while changes in attacking efficiency and defending efficiency are also important, all together explaining 58% of the variation. Teams at the bottom of the distributions have similar characteristics for both win percentage and change in win percentage as those teams in the middle and the top of the distributions, although there are some slight differences in the magnitudes of the statistically significant variables. These results suggest that lacrosse players and coaches should focus on obtaining additional goals and assists while concurrently minimizing the opponent’s goals to increase win percentage and changes in win percentage.

Keywords: distributional impacts, quantile regression, women’s college lacrosse

INTRODUCTION

Since the advent of sabermetrics pioneered by Bill James and the popularity of Lewis’s (5) Moneyball, the use of statistics to analyze sports has exploded in popularity. Reep and Benjamin (7) applied statistical analysis to team-wide factors in soccer where they investigated how the passing skill and position of a player on the field impacts goals. When analyzing a team’s performance, it is essential to determine which factors lead to a team’s success. Most research in this field has focused on professional sports. Busca et al. (1) examine eleven high-stakes international soccer tournaments to determine where a penalty kick is most likely to be struck. Pelechrinis and Winston (6) develop a framework that is comprised of publicly available data to determine the expected contribution of an individual professional soccer player to the probability of his team winning the game. Alberti et. al. (1) examine goal-scoring patterns in four different professional soccer leagues and find that the majority of goals are scored in the second half of the game with the most goals being scored in the last fifteen minutes of play. Castellano et. al. (3) analyze professional soccer match statistics to determine which factors impact winning, drawing, and losing a game and find that shots, shots on goal, and ball possession are important on the offensive end of the field, while total shots received and shots on target received are important on the defensive end of the field. A notable departure from research that focuses on professional soccer is Joslyn et al. (4), who examines the factors that improve the change in win percentage in men’s Division 1 (D1) college soccer. They find that improving shots, attacking, and defending positively impact the change in win percentage between two consecutive seasons.

This research utilizes the tools found in the team-focused literature from soccer and extends it to lacrosse. Soccer and lacrosse have many similarities, especially regarding possession, assists, goals, and defense. There are also marked differences between the two sports in addition to the obvious one: in soccer the ball is kicked while in lacrosse the ball is played with a net attached to a stick. Lacrosse is a higher-scoring game due to the presence of a 90-second shot clock and defending a women’s lacrosse player is more difficult in lacrosse than it is in soccer. One reason for this is that in lacrosse it is a foul to “move into the path of an opponent without giving the opponent a chance to stop or change direction, and causing contact” (page 51, 2022 and 2023 NCAA Women’s Lacrosse Rules Book (6)), while there is no such rule in soccer. Another reason is due to a rule in women’s lacrosse called shooting space (page 54, NCAA 2022 and 2023 Women’s Lacrosse Rules Book (6)), which states that “with any part of one’s body, guarding the goal outside or inside the goal circle so as to obstruct the free space to goal, between the ball and the goal circle, which denies the attack the opportunity to shoot safely and encourages shooting at a player” while soccer does not have a comparable rule. According to NCAA Statistics (7), the average number of goals per game scored in D1 women’s college lacrosse in 2023 was 12, while the average number of goals per game scored in D1 women’s college soccer in 2023 was 1.39. Another notable difference between lacrosse and soccer is that the offside rules are very different. The offsides rule in lacrosse states that there must be at least five defenders behind their defensive restraining line and at least four offensive players behind their offensive restraining line (page 61, NCAA 2022 and 2023 Women’s Lacrosse Rules Book (6)). The offsides rule in soccer is much less stringent and it states that when in the opponent’s half of the field “the player is not closer to the opponent’s end line than at least two opponents” (page 52, NCAA 2022 and 2023 Soccer Rules Book (7)). These disparities between lacrosse and soccer may result in differences in which factors impact win percentages and changes in win percentages.

This research examines which factors lead to an increase in win percentage and change in win percentage for women’s Division 1 college lacrosse teams. We also seek to determine if these factors differ among teams in the 25th, 50th, and 75th percentiles for win percentage and the change in win percentage. Using data from the 2023 women’s D1 college lacrosse season, we explain 86% of the variation in win percentage. Goals, unassisted goals, and participation in the NCAA Championship tournament have a statistically significant positive impact on win percentage, while opponent’s goals and if the team was new in 2023 have a statistically significant negative impact on win percentage. The most crucial factor explaining the change in win percentage between the 2022 and 2023 lacrosse seasons is an improvement in the change in total shots ratio, while changes in attacking efficiency and defending efficiency are also statistically significant, all together explaining 58% of the variation. The variables that explain both win percentage in a single season and the change in win percentage between seasons are similar between the 25th, 50th, and 75th percentiles. This suggests that teams at the bottom of the distributions should focus on the same factors as those at the top when they seek to improve during a season and between seasons.

METHODS

Data Source
Win percentage was collected from the National Collegiate Athletic Association (NCAA) archives for the 2023 and 2022 seasons. A win was awarded one point while a loss was awarded zero points. Offensive and defensive statistics for the 2023 and 2022 seasons were collected from each University’s women’s lacrosse website housed in the season’s cumulative statistics. It is important to note that these data are provided by individual institutions and therefore the statistical findings of this research is dependent on the accuracy of the information provided by each school. In addition to winning percentage, data was collected on goals, assists, shots, opponent’s goals, opponent’s shots, unassisted goals, ground balls, turnovers, caused turnovers, draw controls, whether the team was new to NCAA D1 lacrosse in the 2023 season, and if the team made the NCAA Championship tournament in 2023. Of the 126 D1 women’s lacrosse teams, 123 had information on every variable listed above.

Variables and Distributions

This analysis aims to determine what factors impact a single season winning percentage and which factors impact the change in win percentage across two consecutive seasons. Figure 1 is a histogram of win percentage for the 2023 women’s lacrosse season. The average win percentage was close to 50% at 48.27%; the minimum win percentage was 0 for the two teams that lost every game during the season, while the maximum win percentage was from a team that won 95.65% of their games. The team with the second-highest win percentage won the 2023 NCAA National Championship tournament.


Summary statistics for the 2023 D1 women’s lacrosse 2023 season are found in table 1. The average number of goals and opponent’s goals nearly offset each other at 211 and 210, respectively. There was an average of 495 shots with a large standard deviation of 105. Below half the goals were aided by an average of 92 assists, while over half of the goals resulted from an average of 119 unassisted goals. There were nearly twice as many turnovers as there were caused turnovers, 7% or a total of 8 teams were new D1 lacrosse teams in 2023, and 24% of the D1 lacrosse teams made the NCAA end-of-season tournament.


Figure 2 contains a histogram of win percentage change, which is constructed by taking the win percentage in the 2023 lacrosse season and subtracting the win percentage in the 2022 lacrosse season. There are fewer observations in the change in win percentage because the seven teams who were new in the 2023 season did not have any statistics for the 2022 season. On average, most teams had a similar win percentage in 2023 as they did in 2022, with an average change in the win percentage of .16. The team with the lowest change in win percentage between the two seasons of -51.47 had a win percentage of 75% in 2022, dropping to 24% in 2023. At the other end of the spectrum, the team with the highest change in win percentage won 12% of their games in 2022 and improved to winning 50% of their games in 2023.

Following Joyce et al. (4), we construct three measures of team success to explain the change in winning percentage: total shots ratio, attaching scoring efficiency, and defending scoring efficiency. The first measure, total shots ratio, is constructed as

The total shots ratio in both 2022 and 2023 is .5, which means, on average, teams are matching their opponent’s shots with their own shots with a range in values from .23 to .7 in 2023 and .3 to .63 in 2022.  This finding for lacrosse compares favorably to what Joyce et al. (4) found for D1 college soccer, where the total shots ratio ranged from .24 to .69 in D1 men’s soccer.

            The second measure of team success is attacking scoring efficiently or goals to shots ratio.

The average attaching scoring efficiency for 2023 and 2022 was .42. This measure had a relatively smaller variability than the total shots ratio, with a minimum of around .3 for both years and a maximum of .5 in 2023 to .58 in 2023. This maximum means that the teams with the highest attacking scoring efficiency earn an average of one goal for every two shots. Being able to convert shots into goals is an essential aspect of winning games. Lacrosse teams are much more likely to convert shots into goals, as Joyce et al. (4) found an average attacking scoring efficiency of .1 or 1 goal for every ten shots in D1 men’s soccer.

The third measure of team success is the defending scoring efficiency, which is contracted as

This final measure determines if teams can prevent opponents from turning shots into goals. The average values for defending scoring efficiency are slightly higher than attaching scoring efficiency, with an average of .43 in 2023 and .44 in 2022. The variability is higher for defending scoring efficiency than attacking scoring efficiency, with a minimum of .31 in 2023 and .34 in 2022 and a maximum of .66 in 2023 and .77 in 2022. Teams that are better at preventing shots from being converted into goals typically have a higher win percentage.

Regression Model
The first step in our regression analysis is to empirically estimate the degree to which offensive and defensive statistics impact the win percentage for the 2023 lacrosse season. The win percentage regression model takes the form:

where  is the error term and i is the individual women’s lacrosse team.  This model is estimated using ordinary least squares to obtain the average marginal impact of each of the 11 variables, as well as using quantile regression at the 50th, 25th, and the 75th percentiles of the win percentage.  Quantile regression is a statistical method that estimates the association between the explanatory variables for a conditional quantile of the dependent variable, see Walmann (8) for a more detailed explanation.  In this application, we use quantile regression to determine if teams at the lower end of the win percentage distributions display different characteristics than those at the median and the top end of the distributions.

            The second part of the analysis follows Joyce et. al. (4) to determine what factors impact the change in win percentage between the 2023 and 2022 lacrosse seasons.  The regression model is as follows

where ε_i is the error term and i is the individual women’s lacrosse team. As with the individual season analysis, this model is estimated using ordinary linear regression and quantile regression at the 50th, 25th, and 75th percentiles.

RESULTS

Table 3 contains the results for the estimation of equation (4) from the 2023 lacrosse season with robust standard errors in parentheses. Looking first at the results from the ordinary least squares model, 86% of the variation in win percentage is explained by the 11 independent variables. Turning to the variables that are statistically significant, each additional goal results in an increase of .18 in win percentage, while each opponent’s goal results in a decrease of .2 in win percentage, with goals and opponent’s goals nearly offsetting each other. On average, one additional unassisted goal results in an increase of .13 in win percentage. Being a new D1 women’s lacrosse team in 2023 results in a 9 point marginally statistically significant decrease in win percentage relative to teams that have been in the league in previous years. This result suggests that new D1 teams have a difficult time navigating their first year likely due to players and coaches lacking experience and chemistry, making obtaining wins more difficult. Women’s lacrosse teams who participated in the 2023 NCAA Championship Tournament have a statistically significant almost 5 point higher win percentage than those who did not participate in the tournament. This finding is not surprising given that the two ways to get a team into the tournament are to either receive an automatic bid by winning their conference tournament or earn an at-large bid by having a compelling enough record during the regular season and conference playoffs.


The last three columns of table 3 contain quantile regression results at the 50th, 25th, and 75th percentiles of the win percentage distribution. Opponent’s goals are the only statistically significant factor to explain wins across all three percentiles. The magnitude of opponent’s goals is largest at the 25th percentile at -.24 and is -.20 for both the 50th and 75th percentile. Teams at the 25th and 50th percentiles of the win percentage distribution that participates in the NCAA end-of-season tournament has a statistically significant 7 point and 6 point higher win percentage, respectively, relative to those who did not participate, while this variable is not statistically significant at the 75th percentile. This may be because most, 73%, of the tournament participants come from the teams at the top 25% of the win percentage distribution, while most teams at the middle and bottom of the distribution did not participate in the tournament. Aside from this difference, the results are similar between the models at the three points in the win percentage distribution.

Table 4 contains the second part of the regression analysis which estimates equation (5) that attempts to determine what factors impact the change in win percentage between the 2023 and 2022 seasons. The variables contained in this analysis mimic those in Joyce et. al. (4) for men’s D1 college soccer. Looking at the OLS results, teams that had a one unit increase in the change in total shots ratio between the two seasons had a 2.4 increase in the change in win percentage. Teams with a 1 unit increase in the change in attacking efficiency had a 1 unit increase in the change in win percentage, and teams with a one unit increase in the change in defending efficiency decreased the change in win percentage by 1.2 points. The statistical significance between these lacrosse results and those found for soccer by Joslyn et al. (4) are identical, suggesting that even though there are many differences between the two sports, the same factors are important in explaining the change in win percentage between consecutive years. Comparing magnitudes between the two applications is not possible because the estimation methods differed. The statistical significance of the variables included in the quantile regression evaluated at the 50th, 25th, and 75th percentiles were the same as in the OLS regression. The quantile regression performed at the 25th percentile of the change in win percentage had the highest impact for the change in total shots ratio and the change in attacking efficiency, while the change in defending efficiency had the smallest impact. The change in total shots ratio and the change in attacking efficiency had the smallest impact for those teams at the 75th percentile, while the change in defending efficiency had the largest impact for those teams at the 50th percentile. These results suggest that the factors that impact the change in win percentage are similar across teams at the bottom and the top of the change in win percentage distribution, although the marginal impacts differed slightly between the percentiles.

Discussion

It is not surprising that additional goals led to an increase in win percentage and an increase in opponent’s goals led to a decrease in win percentage. However, it was unanticipated that many of the other offensive and defensive statistics included in the regression were not statistically significant. It is likely that these other factors either lead to the team’s ability to score goals, such as shots, ground balls, and caused turnovers, or lead to the opponent’s goals, such as turnovers. One drawback of this research is that it does not investigate how these other factors impact goals and opponent’s goals. One adage in lacrosse is “win the draw, win the game.” Even though draw controls are not statistically significant in explaining win percentage, there was no information contained in the box scores on how many goals were obtained when the team won the draw control or how many goals were conceded when the team lost the draw control. More detailed information would be needed to investigate this relationship further. Other factors that likely explain win percentage and changes in win percentage such as team chemistry, the presence of a star player, the experience of the players and the coaches, and how different game management strategies, such as the usage of substitutes and quickness of play, are not included because they are difficult to measure, not included in the box scores, or both.

For a lacrosse coach or lacrosse player who is looking to improve win percentage between seasons, it is comforting to note that focusing on improving the changes in total shots ratio, attacking scoring efficiency, and becoming better at defending by decreasing the opponent’s goal-to-shot ratio will lead to an increase in the change in win percentage. One major drawback of this research is that it does not point to the factors that cause improvements in these variables and how they feed into additional goals or fewer conceded goals.

CONCLUSIONS

This study is the first to analyze which factors impact win percentage and changes in win percentage for NCAA D1 women’s lacrosse. The regression results suggest that goals, unassisted goals, and those who competed in the NCAA tournament had a positive impact on win percentage, while opponent’s goals and teams that were new in 2023 had a negative impact on win percentage. These factors were similar across the distribution of win percentage at the 25th, 50th, and 75th percentiles. Changes in win percentage between the 2023 and 2022 seasons are positively impacted by the change in the total shots ratio and attacking scoring efficiency and negatively impacted by the change in defending scoring efficiency. Even though there are many differences between lacrosse and soccer, the findings of this research and those of Joyce et. al. (4) that focus on college soccer suggest that the factors that explain changes in win percentage are similar between the two sports. These results also suggest that the statistics that explain win percentage and change in win percentage are similar between teams at the bottom, at the middle, and at the top of the distributions.

Applications In Sport

Women’s lacrosse programs at the collegiate level as well as at the national level can use these results to determine which factors to focus on when attempting to improve their win percentage within a specific year or over the course of several years. This research suggests that teams should emphasize their efforts in practice and in games on factors that increase goals as well as those factors that prevent goals. The lack of empirical analysis at the collegiate level, especially for women’s sports, can be rectified using available data. Additional publicly available information would make individual game analysis more informative such as how winning a draw control impacts goals as well as how focusing on specific factors such as caused turnovers or increasing assists increases goals and therefore positively impacts a team’s chances of winning.

REFERENCES

  1. (1) Alberti, G., Iaia, F. M., Arcelli, E., Cavaggioni, L., Rampinini, E. (2013). Goal scoring patterns in major European soccer leagues. Sport Sciences for Heath, 9(3), 151-153.
  2. (2) Buscà, B., Hileno, R., Nadal, B., & Serna, J. (2022). Prediction of the penalty kick direction in men’s soccer. International Journal of Performance Analysis in Sport, 22(4), 571–582.
  3. (3) Castellano, J., Casamichana, D., Penas, C. (2012). The use of match statistics that discriminate between successful and unsuccessful soccer teams, Journal of Hunan Kinetics, 31, 137-147.
  4. (4) Joslyn, M.R., Joslyn, N. J. & Joslyn, M. R. (2017). What delivers an improved season in men’s college soccer? The relative effects of shots, attacking and defending scoring efficiency on year-to-year change in season win percentage. The Sport Journal, 24, 1-12.
  5. (5) Lewis, M. (2004). Moneyball: The art of winning an unfair game. WW Norton & Company.
  6. (6) NCAA 2022 and 2023 Women’s Lacrosse Rule Book. https://www.usalacrosse.com/sites/default/files/documents/Rules/WLC23.pdf
  7. (7) NCAA 2022 and 2022 Soccer Rules Book. https://www.ncaapublications.com/productdownloads/SO23.pdf
  8. (8) NCAA Statistics, Women’s Lacrosse and Women’s Soccer http://stats.ncaa.org/rankings/conference_trends
  9. (9) Pelechrinis, K., & Winston, W. (2021). A Skellam regression model for quantifying positional value in soccer. Journal of Quantitative Analysis in Sports, 17(3), 187–201.
  10. (10) Reep, C., & Benjamin, B. (1968). Skill and chance in association football. Journal of the Royal Statistical Society. Series A (General), 131(4), 581-585.
  11. (11) Waldmann E. (2018). Quantile regression: A short story on how and why. Statistical Modelling. 18(3-4): 203-218.
2024-04-01T07:01:38-05:00March 22nd, 2024|General, Research, Sport Training, Sports Management|Comments Off on An analysis of the factors impacting win percentage and change in win percentage in women’s Division 1 college lacrosse
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Can there be two speeds in a clean peloton? Performance strategies in modern road cycling

Authors: Karsten Øvretveit1

1K.G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing,

Corresponding Author:

K.G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, Norwegian University of Science and Technology,
Trondheim, Norway, PB 8905, N-7491 Trondheim, Norway
karsten.ovretveit@ntnu.no

Karsten Øvretveit, MSc3, is a physiologist and PhD candidate at the Norwegian University of Science and Technology (NTNU). His research areas include genetic disease risk, physical performance, motivational dynamics, and human nutrition.

Can there be two speeds in a clean peloton? Performance strategies in modern road cycling

ABSTRACT

In the history of professional cycling, riders have always sought competitive advantages. Throughout 20th century, many relied on performance-enhancing drugs (PEDs) which gave rise to a phenomenon called “two-speed cycling”. Throughout its modern era, professional cycling has seen anti-doping efforts repeatedly intensify on the heels of several large doping scandals. Over the past decade, the sport appears to have transitioned away from large-scale systematic doping and towards novel, legal performance-enhancing strategies, facilitated by a close relationship with scientific, technological, and engineering communities. The tools and technologies available to assess the demands of the sport, the capabilities of the riders, and the role of environmental factors such as wind resistance, altitude, and heat are more refined and comprehensive than ever. Teams and riders are now able to leverage these to improve training, recovery, equipment, race tactics and more, often from a very early age. This review explores several key developments in road cycling and their implications for the modern professional peloton.


Key Words: professional cycling; performance-enhancing drugs; marginal gains; performance analysis

INTRODUCTION

The main pack of riders navigating the road in a cycling race, known as the peloton, comprises a wide range of physiological, anthropometrical, technical, and strategical attributes. The role of each rider in a given race is typically based on strengths, weaknesses, and objectives, and can be modified by injuries, fitness level, personal goals, and unexpected in-race developments. The concept of “cycling at two speeds”, cyclisme à deux vitesses, has historically been used to distinguish between chemically enhanced riders and those who ride clean (134). However, despite increasingly stringent doping controls in professional cycling along with a clear shift in doping culture, the concept of two-speed cycling remains.
Given the well-documented benefits of performance-enhancing drugs (PEDs), there is an expectation that the intensification of anti-doping measures in professional cycling leads to more homogeneous performance levels in the peloton by reducing the number of artificially enhanced riders. Although this may be a reasonable assumption, it discounts the many substantial advances made in training, nutrition, technology, and strategy, as well as the growing talent pool of potential professionals and the early age at which they begin to seriously structure their training, racing, and recovery. These factors can differ greatly between teams and individual riders and thus help maintain the two-speed phenomenon. This review provides a brief history of the PED culture and use in professional cycling, followed by an examination of some of the key developments in the sport that has helped preserve the two-speed phenomenon in a peloton riding within an increasingly strict anti-doping framework.

The performance-enhanced past of the peloton

Drugs have been used to enhance athletic performance for millennia, stretching back to at least the ancient Olympic Games (16). Cycling as a profession emerged among working-class men who likened endurance sports to physically demanding jobs where the use of drugs to aid performance was considered the right thing to do (58). Indeed, doping has been pervasive in professional cycling for over 150 years, throughout most of which it was either legal or not subject to testing (34). For decades, riders doped to simply be able to do the job – faire le métier (33). Then, athlete health became a concern and a major driving force to regulate, if not outright ban the use of certain substances. Drug testing in the Tour de France (TdF), the most prestigious event on the race calendar, began in 1966. Despite this, amphetamines, cortisone, and steroids remained widespread in the professional peloton. It was also around this time that rumors about the use of blood transfusions in athletes began (60). The year after Raymond Poulidor underwent the first drug test in the TdF, Tom Simpson collapsed on the ascent of Mount Ventoux and later passed away due to an unfortunate combination of alcohol, amphetamines, intense heat, and extreme physical exertion. Although this event brought more attention to the use of stimulants and other drugs in cycling and in sports in general (69), doping would persist for decades to follow. Based on interviews with riders on a professional cycling team at the turn of the millennium, psychiatrist Jean-Christophe Seznec (115) asserted that professional cyclists are not only prone to develop an addiction to PEDs, but also recreational drugs, noting the importance of explicitly acknowledging this risk in order to mitigate it.

When professional cycling entered the 90s, the banned yet at that time undetectable erythropoiesis-stimulating agent (ESA) recombinant human erythropoietin (rHuEPO) arrived in the peloton (101), and performances hit a new level. Increasing circulating erythropoietin (EPO) by illegal means has been perceived by some riders and coaches to give an estimated performance boost, without the term “performance” being strictly defined, of 3% to 20% (31, 100, 134, 138). Interestingly, despite its popularity in the peloton, the research literature on the effects of ESAs such as rHuEPO on endurance performance is equivocal. Its effects on hematological values like hemoglobin concentration ([Hb]) and clinical measurements of power and maximal oxygen uptake (V̇O2max) are well-established, but the real-world benefits are not always clear (116, 123).

There are several aspects of professional cycling that are difficult to account for in experimental studies on exogenous EPO, such as the extremely high fitness level of a peaked professional cyclist and the physiological impact of training and racing on parameters such as Hb. A recent randomized controlled trial found no apparent benefit of EPO on relevant performance markers has sometimes been cited to shed doubt on the true effects of the drug (47). However, this study was done in cyclists with an average V̇O2max of 55.6 mL/kg/min, which is substantially lower than their professional counterparts (124). By his own account, former professional Michael Rasmussen saw his hematocrit (Hct) drop from 41% to 36% following the 2002 Giro d’Italia (98), illustrating how blood composition can be severely perturbed by training and racing. Similar values have been observed in other professionals following participation in Grand Tours (17, 89). Using Rasmussen as an example, using rHuEPO to bring this up to 49%, just below the old 50% limit, would represent a relative Hct increase of 36% and result in improved ability to maintain a much higher intensity in training and racing, and consequently greater exercise-induced adaptations.

Throughout the 90s, Grand Tour riders with supraphysiological Hct would traverse France, Italy, and Spain at impressive speeds until it all seemingly came to an end in 1998. Three days before the start of the 85th edition of the TdF, a Festina team car carrying various PEDs was stopped by customs agents at the French-Belgian border. This event marked the start of what later became known as the Festina affair, a major catalyst in cycling’s transition to a cleaner sport. The wake of this scandal saw an increasing number of calls to action against doping, including by the driver of the Festina car (132), with claims of the sport dying unless drastic action is taken. Subsequent large-scale doping cases such as Operación Puerto and the contents of the USADA’s Reasoned Decision Report (10) served as reminders that PEDs were still present in the peloton and strengthened the resolve of those fighting for a cleaner sport.
Although riders are often blamed for the pervasive drug use in cycling, most entered a sport with a lack of top-down anti-doping efforts, leaving them with the difficult choice of either conforming to the culture or competing on unequal terms. One of the most crucial steps towards a cleaner sport is a change in culture among teams and riders. Much, if not most, of the credit should go to the riders themselves, many of which have actively pushed against the use of PEDs for years (46, 50, 59, 85, 130). Today, most doping cases in cycling are among semi-professional riders, whereas the number of riders testing positive at the highest level is approaching zero (88).

Although absence of evidence is not evidence of absence, fewer doping cases at the highest level of cycling suggests that overt, systematic drug use is a thing of the past. Given professional cycling’s checkered history, it would be naïve to think that doping has been eliminated entirely, but the sport does appear to have evolved beyond doping being perceived as all but necessary to gain entry into the professional peloton. Generational shifts not only among riders, but also among governing bodies and team leadership have contributed to an overall firmer stance against doping, removing potentially significant contributors to anti-doping violations (6). There is also indications that the post-Armstrong generation, especially those who started their careers young, are less likely to use PEDs (5), although the evidence is equivocal (64). Additionally, anti-doping technology continues to improve, with recent advances such as gene expression analysis being able to extend the detection window of blood manipulations (28, 133).

Conceptual approaches to legal performance development

It could be argued that the extraordinary performances regularly being on display by the current generation of riders suggest that the dismantling of systematic doping practices has led to progression rather than regression of the sport of cycling. The transition away from prevalent PED use has forced teams and riders to seek out other areas of improvement, some with barely measurable effects, to keep up. Although seeking improvements in many areas is not a new phenomenon in professional cycling, it has received increasing attention over the past decade with the success of Team Sky, now INEOS Grenadiers, and team director, Dave Brailsford, who called this concept “marginal gains”. Brailsford and his team set out to win the TdF within five years with a clean British rider (29). To achieve this, he brought with him the approach he used as a performance director for British Cycling, which had led to considerable success in track cycling. Team Sky was established on the back of British dominance in the Laoshan velodrome during the 2008 Beijing Olympics, where they took home seven gold medals. As he transitioned from the track to the road, Brailsford brought the idea that compiling enough marginal gains could provide a greater performance advantage than PEDs (87).

Although the marginal gain concept came to prominence with Team Sky during one of professional cycling’s most recent avowed shift from banned to legal performance-enhancing strategies, it has been practiced by cyclists since at least the mid-1900s. Italian Fausto Coppi, who rode to multiple victories in the TdF and Giro d’Italia, as well as in one-day classics throughout the 40s and early 50s, was an early adopter of novel diet and training approaches. After World War II, the sport of cycling was anything but advanced and Coppi set out to change that. He worked with Bianchi to develop bikes and other equipment; he adapted his diet to better fuel his riding – not only its contents, but also the timing and amount; and he explored strategies for how to best race as a team (37). Some of these developments would later influence other greats, such as Eddie Merckx, who, among other things, was obsessed with proper bike fit (38). Current director of the French national team, Cyrille Guimard, has also long been known for his application of cutting-edge technology and training methods. One of his former riders, Laurent Fignon, described him as being “right up-to-date. He had files for everything. He was interested in all the lates training methods. Where his protégés were concerned, he would look at the very last detail and even the slightest defect would be corrected. He knew how to ensure everyone had the very best equipment that was on the market: made-to-measure bikes, the newest gadgets.” (32, p. 56).

 The notion that modern riders can surpass past performances solely through legal performance strategies rests on the assumption that these strategies, particularly when combined, are highly effective. Furthermore, a larger pool of athletes and an earlier onset of structured athletic development might amplify these effects. The following section explores the degree of improvement that can be made in the areas of training, nutrition, and technology.

There is not a single anthropometric or physiological characteristic that is completely uniform across high-level cyclists (65, 111). Those with elite potential tend to have stand-out absolute measurements of aerobic fitness and power, but these are attributes that can also be found in cyclists of lower caliber. Elite riders also possess very high power-to-weigh ratios, typically expressed as watts per kilogram (W/kg). An emerging concept that may also distinguish riders of different caliber is durability, i.e., the point and degree of physiological decline during extended exercise (66, 79, 80). Laboratory measurements of key performance determinants such as power-to-weigh ratio, V̇O2max, cycling economy, critical power, and peak power output provide a detailed physiological profile of each individual rider but cannot accurately predict real-life performance.

Training Strategies

Aided by technology, experience, and insights from a growing body of research, training is more refined, structured, and supervised than before, with most, if not all, training sessions serving a specific purpose. Each rider typically follows an individualized training plan that is carried out under comprehensive monitoring of variables such as heart rate, power output, climate, and terrain. These data, along with laboratory measurements, race outcomes, and even psychological variables, are used to adjust volume, frequency, intensity, and/or modality throughout the season. This allows each rider to absorb as much recoverable training volume as possible to optimize physiological adaptations and peak repeatedly for competition while avoiding overtraining. Whereas virtually every single pedal stroke of the modern rider is quantified and analyzed to guide training, racing, and recovery, riders of the past relied more on “feel”, often opting for subjective rather than objective measurements of output. During the 1987 TdF, Laurent Fignon declared his legs to be “functioning again, more or less”, but did not see the value in monitoring his heart rate, explaining that “I lost my temper with those blasted pulse monitors: I handed mine back so that it wouldn’t tell me anything anymore” (32, p. 182).

Although W/kg is often favored as an indicator of riding capacity and a way to quantify cycling performances, a large V̇O2max has long been considered a basic requirement of entry into the professional peloton. Values reported for GC contenders are generally comparable between generations, with the lowest value found in the most dominant TdF rider of all time, albeit with an asterisk (table 1). There are a few caveats to these numbers, such as the validity of the actual measurement, most of which are not described in the research literature but rather in media. Moreover, oxygen uptake does not increase in proportion to body mass and scaling V̇O2max to whole body mass is thus not appropriate when comparing athletes of different body sizes (71). Although some of these values may be exacerbated by PED use, both the baseline level and plasticity of V̇O2max are under considerable genetic influence (15, 86, 135), and WorldTour levels can be reached without doping in those with sufficient genetic predisposition and appropriate stimulus.

Interestingly, there seems to be a physiological trade-off between efficiency and power, where adaptations towards the latter may attenuate the former (72, 113). This phenomenon was observed in Norwegian cyclist, Oskar Svendsen, who once had the highest V̇O2max ever recorded. Svendsen showed promise early by becoming junior time trial champion with less than three years of training and placing high in Tour de l’Avenir. However, despite an incredible V̇O2max of 96.7 ml/kg/min at 18 years of age, Svendsen never became a WorldTour rider. Although his early retirement at age 20 left his potential at the elite level largely unexplored, the reduction in cycling economy he experienced with increased training load could have been resolved as he matured as a rider, as cyclists appear to become more efficient over the span of their careers with little change in V̇O2max (112). If he remained active, Svendsen may eventually have been able to exploit his incredible baseline to reach the proverbial second speed in the modern peloton without chemical assistance. These insights into Svendsen’s physiological profile not only reveal some of the physiological complexities involved in high-level endurance performance, but also serve as an example of the scientific resources available to modern teams and riders that allows for a level of detail in the assessment and follow-up of athletes never seen before at that level of the sport.

Among the many training-related advances in the modern era is a more systematic approach to altitude training. Altitude-mediated erythropoiesis has long been recognized as an exposure that can produce adaptations that improves performance at sea level, as well as acclimatize athletes to sustain performance in hypobaric conditions. There are several ways to approach altitude training and care should be taken to avoid carrying the detrimental effects of prolonged hypoxic exposure, such as reduced cardiac output (Q̇) due to hypovolemia (117), into competition. Today, professional cycling teams rely on both experience as well as past and emerging research to use altitude as an important preparatory measure in various parts of the season. As the individual responses to hypoxic conditions can vary greatly (93), a large hematological response following real or simulated altitude exposure is an important attribute in modern riders. If done properly, altitude training can induce comparable hematological changes to rHuEPO use (table 2), making it a crucial performance-enhancing strategy in the modern peloton. Increasing [Hb] not only improves V̇O2max by improving the oxygen-carrying capacity of blood (43), it also enables sustained work at a higher fraction of maximal capacity (40) and faster V̇O2 kinetics (18), which can be hugely influential in a peloton with limited interindividual difference in V̇O2max.

A more recent strategy to legally induce hematological adaptations is heat acclimation. Prolonged exposure to heat is associated with both increased plasma volume, which can improve stroke volume and consequently Q̇ and V̇O2max, as well as an expansion of total hemoglobin mass (Hbmass) (91). In fact, light exercise in a heated environment five times per week has been shown to increase Hbmass by 3% – 11% in endurance athletes (90, 103, 107). Due to the logistical challenges and cost related to with altitude camp designs such as live high-train low, heat acclimation training may offer a more accessible strategy for riders and teams with less resources, or an additional stimulus to regular stays at altitude.
The mechanistic similarities between synthetic and natural causes of erythropoiesis makes it physiologically possible to harness the benefits of EPO without doping. Voet (132) recounts that pre-scandal Festina riders did not even bring EPO to altitude camps because it was going to be “useless”. Describing his first stay at altitude, formerly enhanced rider, Thomas Dekker, wrote that “[t]he altitude works its magic: the thin air jolts my body into producing extra red blood cells and the Swiss Tour is the first race in ages where I can stay with the pace on the climbs” (25, p. 135), expressing relief that he could hang with the peloton without PEDs. Michele Ferrari, Lance Armstrong’s coach during the height of his career, argues that the effects of EPO on hemoglobin concentration can be achieved through proper altitude training alone (31).

Every rider in the professional peloton possesses rare abilities as cyclists. Given that the sport selects for individuals with above average baseline values of [Hb] and Hct, it may not take much stimulus to maintain a high level. However, compared to simply administering rHuEPO, strategies such as altitude training and heat acclimation are more complex undertakings, partly because of potential drawbacks with that must be accounted for, such as transiently reduced Q̇ and altered dietary requirements. The financial cost associated with prolonged exposure to altitude and/or heat for a professional team is also a considerable barrier, as the finances of teams can differ greatly. In some cases, PED use might simply just be more practical than legal strategies, and not necessarily more powerful.

Improving oxygen delivery and utilization have been main training targets for cyclists throughout most of its history, while resistance training (RT) has been largely neglected. As the impact of both power output and oxygen consumption on cycling performance is intrinsically related to rider weight, maintaining a low body mass has been, and still is, imperative. However, RT with an emphasis on neural adaptations can substantially improve force-generating capacity and reduce the oxygen cost of exercise in athletes without adding unnecessary bulk (51-53, 140). It also helps maintain bone mineral density, which elite cyclists are prone to lose (48, 110). A recent study found that RT with traditional movements and individualized load improved bone mineral density and endurance performance in professional cyclists (126). Moreover, it appeared to improve strength, power, and body composition to a greater degree than short sprint training, a more traditional power training modality for cyclists, supporting the role of structured RT as a part of a professional cyclists overall training program. Indeed, evidence for the benefit of RT on cycling performance has been mounting over the past years (table 3) (62, 102, 104-106, 108, 109, 120, 131, 141). This has contributed to changing the way RT is perceived and applied in the.

An elite physiology is easier to perturb than improve. At the highest level of cycling, large adaptations to training are unlikely to occur in the short term. The full, natural potential of a rider can only be reached via the cumulative effects of proper training and recovery, both of which are highly dependent on proper fueling.
Nutrition, body composition, and supplementation

In Jørgen Leth’s classic documentary, “A Sunday in Hell”, Roger De Vlaeminck can be seen consuming a plate of meat with his team before setting out to defend his multiple Paris–Roubaix victories from the previous years in the 1976 edition, with the narrator explaining that “a rare steak is a good breakfast for what lies ahead” (67). This is in stark contrast to the low-residue diet often consumed by riders in the modern peloton (39). A low-residue diet is characterized by a very low fiber content, which can reduce rider weight and consequently improve race performance (36). This diet is usually combined with a very high carbohydrate intake throughout a race to ensure constant glucose availability, and the reduced satiety that can be associated with low-residue diets may even help a rider maintain energy intake during a race. The exact amount differs between riders, with numbers around 100 g of carbohydrate per hour being a rough estimate that may be exceeded considerably on hard days. The recognition of the added performance benefit of increased carbohydrate intake has given rise to the concept of gut training for athletes (56, 78). Racing hard for hours on end for multiple consecutive days with limited glucose availability is guaranteed to hamper performance compared to a well-fueled athlete; as red blood cells do not convert to adenosine triphosphate; blood doping cannot replace bioenergetic fuel.

There are some examples of riders that leveraged nutrition to increase their performance throughout history, such as Fausto Coppi (37), but in the modern era, all riders pay attention and have access to both nutritionists and chefs, both of which are roles that have become integral parts of professional teams. Riders also have access to more knowledge and tools, such as food apps powered by machine learning (121). The days of training hard during the day following by alcohol consumption in the evening and racing on the weekends are gone, but were reportedly common until fairly recently (25, 54). The culmination of evidence- and experience-based diets in professional cycling has led to better fueling strategies and lower body mass in the peloton and perhaps especially among the best riders.

Although described as “thin as rakes” (132, p. 63), the riders of the 90s were heavy by today’s standard. Laurent Fignon (32) explains that the importance of power-to-weight ratio did not become known among the riders before the mid-80s and that he, until that point, paid little attention to diet. Looking at the top 10 finishers of the TdF for the past four decades, starting with the latest edition, suggest that it is becoming more and more of a requirement for the overall GC placing (table 4). Notably, between 1992 and 2022, the average BMI of the top 10 decreased by 8.1%. This trend seems to generally hold across all Grand Tours for the past decades (118).

Supplements such as creatine and beta-alanine have been shown to improve endurance performance, including in cycling (7, 12, 21, 49, 127, 128). Creatine was introduced to the peloton in the mid-90s but was very expensive at the time. Riders who had access to it could consume up to 30 g the day before a long time trial or a mountain stage in hopes of a performance boost (132). Creatine and beta-alanine are now both affordable and widely used, alongside other supplements such as caffeine, electrolytes, nitrates, various vitamins, and minerals, as well as macronutrient supplements such as protein and carbohydrate.

In recent years, a lot of attention has been devoted to exogenous ketones. It is a contentious supplement that has been embraced some of the strongest teams while being recommended against by the Union Cycliste Internationale (UCI) and the Movement for Credible Cycling (MPCC). Ketones, or ketone bodies, are acetyl-CoA-derived metabolites that are produced by the liver under conditions with reduced glucose availability, such as low-carbohydrate diets, fasting, and during or after hard exercise. Ketone bodies such as β-hydroxybutyrate can spare glycogen by inhibiting glycolysis and acting as an alternative fuel in oxidative phosphorylation, which in turn can improve endurance (19). As with the research on other legal and illegal enhancement strategies, the degree to which exogenous ketones translates to improved exercise performance remains to be fully elucidated (24, 92, 94, 96, 125, 139). Although there may be potential drawbacks with isolated ketone supplementation (82), in conjunction with sodium bicarbonate, which is a weak base that has been used for some time in endurance sports (45), ketone supplementation has been shown to improve power output towards the end of a race simulation by 5% (95), although this effect may be unreliable and warrants further study (97).

Much of the hype surrounding some of the proposed effect of ketones as an energy substrate appears unwarranted, but emerging evidence suggest that it may have intriguing properties as a signaling molecule. A few years ago, it was shown that infusion of ketone bodies increased circulating EPO levels in healthy adults (63). The impact of ketones on EPO is supported by the observation that adherence to a ketogenic diet can increase [Hb] and Hct by ~3%, with the caveat this effect is within the biological variation of these markers (83). Recently, Evans et al. (30) found that ingestion of ketone monoester after cycling exercise increased serum EPO concentration, providing further evidence that it may be the signaling effects rather than nutritional value of ketone supplements confers the greatest performance benefit for professional cyclists.

Technology and equipment
Science tends to be reductionistic by necessity, whereas a cycling race is much more open-ended. There is, however, a certain cycling event that is performed in highly controlled conditions and relies heavily on technological advances that can serves as a good example of marginal gains in modern road cycling: the hour record. In 1972, Eddy Merckx, perhaps the greatest cyclist of all time, rode a distance of 49.431 km to set a new hour record for the first time since the 1950s. Twelve years later, Francesco Moser breached 50 km with an effort totaling 51.151 km, aided by disc wheels and a skin suit. The following years would see various innovative approaches by riders such as Graeme Obree and Chris Boardman, until the UCI decided to revise the rules in 1994 and again in 2014 (table 5). To set his records, Boardman worked closely with Brailsford’s predecessor in British Cycling, Peter Keen, and then later with Brailsford himself after his retirement, on what would be the beginning of British riders’ marginal gains on the track and later in the peloton (14).

From Voigt’s first attempt to Ganna’s latest, the modern hour record has been improved by over 11%. Although Ganna is a multiple World Time Trial champion and likely one of the most suitable riders to attempt the record, the last person to hold the record before him was Daniel Bigham, the only rider on the list that was never a WorldTour rider. Although an accomplished cyclist in his own right, Bigham’s record is a prime example of how far and fast you can get by maximizing the margins, with his record being set at an average power output approximately 100 watts less than Wiggins. Bigham himself puts his performance down to 50% physiology and 50% equipment (137). One of the main aspects Bigham exploited was aerodynamics; his coefficient of aerodynamic drag (CdA) was ~0.15, which is considerably below what is commonly seen in cyclists, including professionals (41).

Aerodynamics is not only relevant when riding fast around a velodrome for an hour, but also one of the most important things to consider when trying to ride fast on a bike in general. At a riding speed of about 54 km/h, close to the average on a flat TdF stage, approximately 90% of the total resistance is aerodynamic resistance (13, 44). Most of the resistance is caused by the rider himself, with common estimates ranging from 60-82% (74), and the rest by other factors such as equipment (22, 73, 77). The importance of minimizing CdA underlies much of the development of modern bike frames, wheels, handlebars, helmets, clothing, and more. In recent years, there has been less emphasis from manufacturers on getting their bikes down to the UCI weight limit of 6.8 kg in favor of more aerodynamic optimizations. This approach is supported by findings showing that simply opting for aerodynamic rather than light wheels will reduce climbing time on 3% – 6% grade hills (57). Steeper hills favor lighter wheels and WorldTour riders often make specific selections of wheelset, gear ratio, and even frameset based on race or stage profile. Some teams take it a step further, such as Jumbo-Visma, who use a portable aero sensor to measure exact wind conditions on race day and make equipment selections accordingly (81).

Since the inception of professional cycling there have been numerous technological advances and there is still a steady flow of innovations reaching the peloton. Some of these become widely adopted, such as aero-optimized gear; some are providing new alternatives without replacing old ones, such as tubeless tires (riders still use a variety of tubed, tubeless, and tubular tires); and others are replacing without immediately improving a function, such as disc brakes. Technology has also enabled more extensive monitoring of athletes, both on and more recently off the bike. For instance, several teams are now measuring body temperature and hydration status, and by analyzing the individual sodium composition sweat, can select the appropriate supplementary amount of sodium for each rider. During very hot days, riders are often seen wearing cooling gear to keep body temperature down. This can not only keep the riders comfortable, but may also benefit their performance in the race by lowering thermal strain (75).

Although professional cycling continues to benefit from science, technology, and engineering, the UCI have rules and regulations in place that ensures that cycling does not, for better or worse, stray too far away from its origins. Although these are subject to change based on new developments, they sometimes can become more restrictive, such as the recent ban on handlebars narrower than 350mm. Riders with the ability and resources to combine effective performance strategies from training, nutrition, recovery, and technology – perhaps especially strategies with small effects that are more likely to be ignored by others – may find themselves able to ride at a different speed than the rest of the peloton.

Merging the margins

Imagine a gifted and durable athlete with an exceptional ability to consume oxygen across all intensity domains, maintain a low body mass, effectively utilize lactate, absorb and recover from a high training load without injury or illness, handle training and race nutrition, thermoregulate in various climates, and respond well to altitude and heat exposure finding his or her way into cycling early in life. Suppose this young cyclist learns to maintain an aerodynamic position on the bike, pedal with an efficient cadence, move seamlessly through the peloton, avoid accidents, calmly handle the pressure of competition, and execute winning moves. Professional cycling selects for individuals with supraphysiological potential from environments that have allowed this potential to be expressed. Then, it awards those who have made it to the starting line and are able make as many performance determinants as possible come together on race day.

Increased professionalism at the highest level of the sport trickles down to the amateur and junior ranks, exposing up-and-coming cyclists to favorable conditions at an earlier age, leading to greater improvements in physiology, psychology, and race craft. Some riders may show incredible promise in some aspects of racing and struggle with others. Oskar Svendsen, V̇O2max world record holder, undoubtedly had one of the greatest physiological potentials ever seen in a rider. However, he admittedly also had technical and tactical challenges: “Cycling is a monotonous sport, yet so complex and driven by tactics that you won’t win races unless you deliver on all those qualities. I came into the sport with good physical qualities, but I struggled most with the tactics and patterns. I did learn a lot in my senior years on Team Joker though, even if I still had a long way to go. Descending down hills was also something I struggled a lot with, and it sapped much of my energy in races.” (99) Svendsen’s career serves as an example of how cycling is not only a physiological sport, but also technical, tactical, and psychological. Recently retired rider, Richie Porte, described former TdF GC winners Chris Froome and Tadej Pogačar as “psychological beasts” and noted that cycling has become increasingly scientific, which does not suit all riders (35). Modern riders are more methodical, data driven, and regimented than before. This reduces the human element of the sport, to the dismay of those claiming that this will increase predictability. Some researchers in the field have also warned against measuring just for the sake of measuring, and advise that rider data should serve a specific purpose (55).

The widely established routine of constant fueling during training and racing not only acutely increase work capacity but also improves subsequent recovery by preventing the rider from becoming completely depleted. This is in stark contrast to the days when reaching for your bottle during a hard training ride, even if it only contained water, was considered a weakness. Paul Köchli, former coach of riders such as Bernard Hinault and Greg Lemond, once said that the art of cycling is to do the right thing at the right moment (27). This is true not only in the context of a race, but indeed for the professional cyclist’s career as a whole. The effects of proper training, nutrition, and recovery accumulate not only throughout a season, but a whole career, benefitting those who consistently do the right things from early on.

Conclusion and future perspectives

In some ways, modern approaches to improving cycling performance represent a first principles approach to cycling and a fundamental challenge of conventions, within the rules and regulations of UCI. It seems to have restored some of the faith in the sport that was once lost with various doping scandals. Given the measurable impacts of legal performance-enhancing strategies, many of which were previously unknown or overlooked, it could be argued that combining these effects can bring a clean rider’s performance close to, or even surpass, that of an enhanced cyclist, assuming a gifted baseline and sufficient degree of adaptability.

Suggesting that it is possible to win at the highest level in cycling without the use of PEDs is not the same as claiming that the sport is completely clean. As others have pointed out, periods that have previously been perceived as clean have later been shown to be anything but (26). This paper covers some of the key legal advances in road cycling that has contributed to elite performances in the modern peloton, while at the same time acknowledging that illegal strategies may still be present.

Much of what was once considered “marginal gains” have now become common in all professional cycling teams. This represents a shift from a culture of doping to a culture of exhaustive continuous improvement, a lot of which is kept under wraps and some that may even be considered a grey area. Effective anti-doping measures contribute to a more level playing field, but not entirely level. The teams with the most resources often get the most talented riders, allowing them to combine the greatest potential with the best strategies. And even still, there are some who favor optimizing riders and their equipment for weight rather than aerodynamics, ignoring the latter to the extent that it becomes a considerable detriment. In an era of professional cycling where individual performances are influenced by a multitude of human and nonhuman factors, which in combination can have profound effects, the existence of two-speed cycling in a clean peloton is not only logical – it should be expected.

Acknowledgments

This work was supported by the Norwegian University of Science and Technology (NTNU). The author would like to thank Dr. Endre T. Nesse and Dr. Fabio G. Laginestra for their comments and feedback on the manuscript.

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