Paper : Sports Medicine and Rehabilitation

The Occurrence of Physical and Psychological Problems
Among Japanese College Soccer Players:
A Cross-Sectional Observational Study
Naruto Yoshida*, Hideaki Waki*, Yoichi Minakawa*, Shogo Miyazaki* and Masaaki Koido***Department of Acupuncture and Moxibustion, Faculty of Health Care, Teikyo Heisei University

2-51-4 Higashiikebukuro, Toshimaku, Tokyo 170-8445 Japannaruto-y@kch.biglobe.ne.jp**Faculty of Health and Sports Science, University of Tsukuba[Received October 9, 2020; Accepted March 16, 2021]

Conditioning for injury prevention in soccer is important because of the high number of injuries.
Many previous studies have focused solely on physical problems or solely on psychological problems.
In this study, multiple factors were considered to gain a better understanding of the physical andpsychological status of athletes. The current injury, current pain, ankle instability, fundamental
pattern of movement, catastrophic thoughts of pain, daytime sleepiness, sleep dysfunction, andsymptoms of anxiety and depression of Japanese male college soccer players were assessed.
Among the 122 collegiate soccer players who completed all questionnaires and measurements,
43% experienced pain, 27% had injuries, 50% had ankle instability, 21% were restricted in theirfundamental patterns of movement, 20% had catastrophic thoughts of pain, 48% experienced
daytime sleepiness, 20% experienced sleep dysfunction, and 14% experienced symptoms of anxiety
and depression. Only 11% of the athletes showed no physical or psychological problems. Eightynine percent had either a psychological or physical problem, and almost half of the cohort (48%)
experienced both physical and psychological problems. This study demonstrated how difficult it isfor athletes to reach their peak condition, as factors other than ‘skill’ also play a role in conditioning.
Assessment of both physical and psychological aspects is needed to understand the conditioning
status of athletes.
Keywords: psychological and physical condition, sports medicine, observation (cross-sectional) study,soccer, sports injury[Football Science Vol.18, 22-30, 2021]

1. Introduction
The prevalence of injury in professional soccer players
is well known, with the risk of injury estimated to be1000 times greater than for those in the manufacturing,
const r uct ion, and ser vices sectors ( Drawer andFuller, 2002). The risks associated with acute trauma
a nd ost eoa r t h r it is i n t he lowe r ext re m it ie s a reunacceptably high (Drawer and Fuller, 2002). A 15-year
epidemiological follow-up study of Japanese professionalsoccer players reported 2947 injuries from 3984 matches,with an average injury rate of 21.8 injuries per 1000
hours (Aoki et al., 2012). Several studies (Gouttebarge
et al., 2016; Ekstrand et al., 2020) on the occurrence ofsoccer injuries have suggested the importance of injury
prevention in sport. As part of this concept, athlete
conditioning is a critical component of injury prevention.
22

According to the Japan Sports Association, conditioning
should prepare athletes to perform well by addressing
all aspects, including physical, environmental, andpsychological factors (Japan Sports Association, 2006).
I nju r y su r veys are used to ascer t ai n physicalcondition; however, the definition of an injury is often
the most significant factor influencing survey outcomes(Bahr, 2009) Although several studies (Engebretsen etal., 2013; Junge et al., 2009; Stubbe et al., 2015) used“medical attention” (injury resulting in a player receiving
medical attention) or “time loss” (injury resulting in aplayer unable to participate in future training or matchplay) definitions, “any physical complaint” has become
the definition of choice (Fuller et al., 2006a, 2006b,
2006c). This latter definition refers to any physicalcomplaint sustained by a player from a match or training,
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Physical and Psychological Problems in Japanese College Soccer Players

regardless of the need for medical attention, or timeaway from sporting activities (Fuller et al., 2006a,
2006b, 2006c). This broad definition (Clarsen and Bahr,2014) captures physical symptoms, including bodily
discomfort (pain, swelling, or limited range of motion)and functional limitations, which are often overlooked by
the “medical attention” and “time loss” definitions (Bahr,2009; Clarsen et al., 2013; Clarsen et al., 2014). Pain issignificant as it is often an early symptom of injury andhas been recommended as an investigation item by theInternational Olympic Committee (Bahr, 2009).

committee (IRB approval no.: Tai 019-114). The study
also followed the principles of the Declaration of
Helsinki, and was registered as a clinical trial under
the trial registration number: R000046407 UMIN
000040671 on June 6th 2020 by the association between
dynamic alignment and injury occurrence in college
soccer players. All study participants provided written
infor med consent and agreed for their data to beanonymously used for publication

Conditioning should not only account for physicalfactors but also psychological factor assessments. The
prevalence of Common Mental Disorders (CMDs) amongprofessional soccer players in Europe was reported
as follows: 37% experiencing anxiety and depression,
19% sleep disorders, 14% alcohol dependence, and 12%
distress (Gouttebarge et al., 2017). Additionally, theincidences of players with two, three, and four disorders
was reported as 13%, 5%, and 3%, respectively. It
was estimated that at least 3 of the 25 players on
a professional soccer team will experience CMD
symptoms in a single season (Gouttebarge et al., 2017).
Studies have also indicated that professional soccer
players are more likely to develop CMD symptoms after
severe injury (Kilic et al., 2018). In another study, soccer
players who had depression were 10% more likely to be
injured than those with no symptoms (Yang et al., 2014).
Hence, pain may reflect both physical and psychologicalissues. For effective injury prevention, a combination ofstrategies is required to assess all aspects of an athlete’s
condition. To the best of our knowledge, no study has
examined both physical and psychological aspects.

This was a cross-sectional observational study.
A web-based survey questionnaire and functional
movement screen test (Bonazza et al., 2017) comprisingmeasurements were conducted at the University ofTsukuba in March 2020. Measurements were conductedduring the pre-season, when the new team was being
rebuilt up.

2. Study objectives
We hypothesized that Japanese collegiate soccer
players experiencing pain had psychological andphysical issues. Thus, we sought to establish an effective
evaluation method for multiple factors affecting athlete
condition.

3. Materials and methods
3.1. Ethical considerations
This study was approved by the Institute’s Research
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3.2. Study setting

3.3. Study participants
One hundred and sixty (160) Japanese collegiate
male soccer players, included in the affiliation list, werebriefed and provided with documentary study methods
at team meetings. The eligibility criteria included thoseathletes who had taken part or were planning to take partin soccer training. At the time the questionnaire or othermeasurements were administered, if it was anticipated if
an athlete would retire or leave soccer for more than one
year, they were excluded from the study.

3.4. Study variables
We surveyed the following physical factors; thepresence of a current injury, current pain, fundamental
patter ns of movement, and an kle instability. For
psychological factors; we investigated catastrophic
thoughts of pain, daytime sleepiness, sleep dysfunction,and symptoms of anxiety and depression.

3.5. Data sources and study tools
The following metrics were ascertained; current
injury, current pain, ankle instability, fundamental
pat t e r n of move me nt , cat a st roph ic t houg ht s ofpain, day time sleepiness, sleep dysf u nction andsymptoms of anxiety and depression. All items, except
fundamental pattern of movement, were self-reported inquestionnaires.
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Yoshida, N. et al.

Following an extensive review of the literature, aself-report injury questionnaire was developed andamended from Tsigilis and Hatzimanouil (2005). The
final questionnaire, which was reviewed and modified forsoccer, consisted of general information and information
related to physical and psychological factors. The
former included, age, height, weight, soccer experience,and player position. Players were classified into four
positions: Forward (FW), Midfielder (MF), Defender(DF), and goalkeeper (GK). An injury was defined as“a time-loss injury,” which occurred during a footballmatch or practice, and prevented participation in allscheduled matches or practices (Fuller et al., 2006a,
2006b). If players reported any injuries, additional
information was collected through the questionnaire,
including details on whether it was a traumatic orover use injur y, the body region, and injur y type.
Furthermore, injuries were also defined and classified asfollows: traumatic injury; “an injury caused by a specific,
identifiable event,” and overuse injury; “an injury causedby repeated micro-trauma without a single, identifiable
event responsible.” Injury definitions were the sameas injury classifications, according to the International
Olympic Committee injury surveillance system (Junge etal., 2008). For “pain” assessment, participants answered“Yes” if they had pain, regardless of a diagnosed trauma
disorder or not. Fundamental patterns of movement
were evaluated using a functional movement screen(FMS) (Cook, 2014a, 2014b). FMS test movements werecreated for screening fundamental movements, andwere based on proprioceptive and kinesthetic awarenessprinciples. FMS comprised seven basic movement tests(deep squat, hurdle step, inline lunge, shoulder mobility,
trunk stability push-up, rotary stability, and active
straight leg raise). FMS also evaluated the basis of sports
movements, i.e., mobility, stability, and motor control ofeach part of the body in a complex manner. Participants
were recorded from two directions using two video
cameras (Casio EZ-200), one in the sagittal and one in
the coronal plane. Each movement was assessed by aresearcher certified in FMS Level 1.
The Cumberland Ankle Instability Tool (CAIT)
developed by Hiller et al. (2006). Our study used thevalidated Japanese version of CAIT as a measurement
tool for ankle instability (Kunugi et al., 2017). The Pain
Catastrophizing Scale (PCS) was used for catastrophic
thoughts of pain (Matsuoka and Sakano, 2007; Sullivan
et al., 1995), and the Epworth Sleepiness Scale (ESS)
for daytime sleepiness (Takegami et al., 2009). Sleep
dysfunction was assessed using the Pittsburgh Sleep
24

Quality Index (PSQI) (Doi et al., 1998; Doi et al., 2000),
and anxiety and depression symptoms were assessedusing the Hospital Anxiety and Depression Scale (HADS)(Zigmond and Snaith, 1983).

3.6. Study bias
To address potential examiner bias, data from othermeasurements were not disclosed to examiners before
the FMS assessment was completed. The study size wasdetermined by the maximum number of data collection
possible in the study period.

3.7. Statistical analysis
Descriptive statistics for each variable were presented
and a bubble chart created to visualize the distribution ofphysical and mental status of athletes. In this chart, thenumber of athletes was represented by circle size, withnegative physical factors (numbers) on the X-axis andnegative psychological factors (numbers) on the Y-axis.
The criteria for judging physical factors as “negative”
were the presence of current injuries, presence of current
pain, FMS < 14 (adapted from Marques et al., 2017 andTee et al., 2016), and CAIT < 26 (adapted from Tanen etal., 2014). The criteria for judging psychological factors
as “negative” were: PCS (total) ≥ 30 (adapted from
Sullivan, 2009), ESS ≥ 11 (adapted from Carter et al.,2020), PSQI ≥ 6 (adapted from Carter et al., 2020), and
HADS ≥ 15 (adapted from Fischerauer et al., 2018). The
IBM SPSS Statistics 19 package (IBM Corp, Armonk,
NY, USA) was used for all statistical analyses.

4. Results
Of the 160 soccer players on the affiliation list, 122consented and participated, completed all questionnaire,and FMS assessments. Descriptive statistics data for the
122 participants, comprising; average age: 20 years old(95% CI: 20–21 years), average height: 174 cm (95% CI:
173–175 cm), and average weight: 69 kg (95% CI: 68–70kg) are shown (Table 1).
Sports injuries were manifested in 34 (27%) athletes,
including 25 (20%) acute trauma and nine (7%) overuse
disorders. Pain was identified in 52 (43%) athletes, 26(21%) athletes had functional movement patterns as
indicated by FMS, and 61 (50%) had ankle instability
as indicated by CAIT. Clinically high PCS results (PCS
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Physical and Psychological Problems in Japanese College Soccer Players

Table 1 Descriptive statistics of the cohort (N=122)

Variables

Shapiro-Wilk test

Descriptive data ageneral information
Sex ― no.(%)
Men

122 (100)Age（year）

p < 0.05

20 (20-21)

Height（cm）

p ≥ 0.05

174 (173-175)

Weight（kg）

p ≥ 0.05

69 (68-70)

Soccer experience（month）

168 (149-190)

Player position ― no.(%)
1FW

14 (11)2 MF

56 (46)3 DF

39 (32)4 GK

13 (11)

Physical factor
Traumatic injury ― no.(%)

25 (20)

Contact

14 (11)

Non-contact11(9)Overuse injury ― no.(%)

9 (7)Presence of pain

52(43)

Fundamental pattern of movementp < 0.05

FMS < 14 ― no.(%)
Ankle instability：CAIT

15 (14-16)
26 (21)

p < 0.05

CAIT< 26 ― no.(%)

26 (23-27)
61 (50)Psychological factors
Atastrophic thoughts of painp ≥ 0.05

PCS（total）≥30 ― no.(%)
Daytime sleepiness：Epworth Sleepiness Scale (ESS)

24 (20)p ≥ 0.05

ESS≥11 ― no.(%)
Sleep disorder：PSQI

HADS≥15 ― no.(%)
a10 (10-11)
59 (48)p < 0.05

PSQI≥6 ― no.(%)
Symptoms of anxiety and depression：HADS

23 (22-24)

3 (2-4)24 (20)p < 0.05

9 (7-13)17 (14)

When the Shapiro-Wilk test does not follow a normal distribution (p<0.05), it indicates the median (25thpercentile - 75th percentile), and when it follows a normal distribution (p≥0.05), it indicates the mean (95%
conﬁdence interval).

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Yoshida, N. et al.

≥30) were observed in 24 (20%) athletes, 59 (48%)
were severe for ESS, 24 (20%) had sleep dysfunction as
indicated by PSQI, and 17 (14%) had possible anxiety
and depression symptoms according to HADS.
The distribution of psychological and physicalconditions across the study is shown (Figure 1). Thirteen
athletes (11%) had no physical or psychological issues;
30 athletes (25%) had negative physical conditions, and21 athletes (18%) had negative psychological conditions.
Almost half the cohort, i.e., 58 athletes (48%) had both
physical and psychological issues.

5. Discussion

The number of Psychological problems

Previous studies have exclusively focused on either
physical or psychological issues in athletes; however,

The most common physical factor was current pain,
accounting for 43% of athletes, whereas injuries affected
27%. Interestingly, some athletes with no current injury,
experienced pain. An injury was defined as “a timeloss injury” which occurred during a football match orpractice, and prevented participation in all scheduled
matches or practice sessions. Therefore, it was possiblethat some of these aforementioned pains were caused bytrauma or overuse, which were not listed in the injury
survey used in this study. Besides, it might include some
pains which could not be classified as trauma or overuse
even when examined by a doctor. However, it was

2%

4
5%

3

2

it was also important to understand the simultaneous
effects of both on athlete condition. In our study, 11% ofathletes had no physical or psychological issues; 89% had
psychological or physical issues, and almost half (48%)
experienced both issues simultaneously.

2%

11%

1%

9%

7%

2%

1%

3%

2%

7%

15%

7%

8%

2

3

1
11%

10%

0

1

0
4

The number of physical problems
Figure 1 The distribution of physical and psychological conditions; physical issues
1) The presence of a sports injury, 2) Ankle instability (CAIT < 26), 3) The fundamental patterns of movement (FMS < 14),and 4) The presence of current pain.
Psychological issues; 1) Catastrophic thoughts of pain (PCS ≥ 30), 2) daytime sleepiness (ESS ≥ 11), 3) sleep dysfunction(PSQI ≥ 6), and 4) symptoms of anxiety and depression (HADS ≥ 15). Thirteen athletes (11%) had no physical or
psychological condition issues, 21 athletes (17%) had a bad physical condition, and 30 athletes (25%) had a bad psychologicalcondition. Approximately half of the cohort, 58 (48%) had both physical and psychological issues.
26

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Physical and Psychological Problems in Japanese College Soccer Players

important to acknowledge there are so many athletes inpain while playing in order to understand their condition.
FMS results were negative for 21% of athletes indicating
restricted fundamental patterns of movement in theseplayers. This was considerably lower than the 82%
incidence reported by Marques et al. (2017), and 34%
reported by Tee et al (2016). However, the low incidence
reported here should not be equated to low importance;
FMS indicates a restricted fundamental pattern of
movement which may require correction.
Ankle instability was detected in 41% of participants,
which was higher than the 23.4% incidence reported
in high school and college athletes (Tanen et al., 2014).
Koshino et al. (2020) also reported a lower incidenceof ankle instability (CAIT ≤ 25) in 19.8% of athletes
from various sports, and in 37.5% of soccer athletes.
However, as ankle instability has been associated withanterior cruciate ligament injuries (Kramer et al., 2007),
Achilles tendonitis (Backman and Danielson, 2011), andosteoarthritis (Hubbard-Turner et al., 2017), and thisissue should be addressed as early as possible.
Catastrophic thoughts of pain affected 20% ofparticipants, which was higher in 291 college athletes
reporting an incidence of 14% (Sciascia et al., 2019).
The HADS created by Zigmond et al. (1983) measured
anxiety and depression separately, whereas the modified
version by Clover et al. (2009) combined the two. Our
results indicated symptoms of anxiety and depression in
14% of participants. Fischerauer et al. (2018) reported asimilar incidence (17%) in 102 injured athletes. However,
our cohort included participants without injuries, whichsomewhat limited this comparison. Weber et al. (2018)
reported that 13.2% (10 ≥ HADS-A ≥ 8), 3.4% (HADS-A≥ 11), 5.5% (10 ≥ HADS-D ≥ 8), and 2.1% (HADS-D ≥11) of athletes had experienced anxiety. Athletes withdepressive symptoms had a higher risk of injury, andpsychological factors were found to influence physicalfactors. Psychosocial interventions such as cognitive
behavioral therapy (CBT) promoted positive emotional
states and increased rehabilitative adherence, both ofwhich facilitated recovery from injury (Gennarelli etal., 2020). Further research is required to determine themost effective psychosocial interventions for specificpsychological factors, the ideal periods for intervention,and how best to implement them after a sports injury.
However, the first step in solving such issues is to have aclear idea on the incidence of these factors.
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Previous studies reported daytime sleepiness in
24.9% (Hoshikawa et al., 2018), 19% (Carter et al.,2020), and 22.5% (Khalladi et al., 2019) of athlete
participants, whereas we recorded 48% in our cohort.
Sleep dysfunction was previously reported in 24.7%
of Japanese athletes (Hoshikawa et al., 2018), 35% ofcollegiate student athletes (Carter et al., 2020), 68.5% ofprofessional soccer players (Khalladi et al., 2019), and
54% of collegiate soccer athletes (Benjamin et al., 2020),
whereas we reported 20%. Since daytime sleepiness andsleep dysfunction are implicated in injury development(Milewski et al., 2014), athletic performances could be
improved by sleep education, and CBT and prolonged
sleep duration approaches (Bonnar et al., 2018).
In general, “mind,” “skill,” and “body” are necessary
attributes to achieve satisfactory athletic performances.
In this study, only 11% of the participants were in a goodcondition of both “mind” and “body.” This study showed
how difficult it was for athletes to reach their peakcondition, as factors other than “skills” also play a rolein conditioning. However, it was clear that assessments,
including both physical and psychological aspects, areneeded to understand athlete condition. In general,
athletes tend to perceive psychological support as
weakness, and hence do not seek it. A lack of knowledgeof mental health and other factors also play a role
(Gulliver et al., 2012). Therefore, to address both physicaland psychological needs, appropriate information should
be offered to athletes and all in their lives, to acquire an
accurate understanding of the nature and importanceof mental health, appropriate self-care, and the needfor physical and psychological support from family andfriends.

6. Study limitations
This was a cross-sectional study, and did not reveal a
causal relationship between factors. A prospective study
is required to examine such relationships. Participants
were Japanese collegiate soccer athletes, with a mean
age of 20 ± 1 years, and 164 ± 35 months of playing time.
Hence, the same trends may not apply to athletes outside
this age group. A study, including a broader age range
is therefore warranted. In addition, although this crosssectional study analyzed the presence or absence of
current trauma and overuse disorders, the past histories
of athlete trauma and over use disorders were notanalyzed. To address this limitation, we hope to clarify
27

Yoshida, N. et al.

the inf luence of past history on current physical andpsychological issues through longitudinal studies.
Study measurements were conducted in early March
2020 and those did not coincide with inactivity due tocoronavirus disease 2019 (COVID-19), but the infection
was spreading and that may have inadvertently affectedstudy results. The conditioning is related to manyfactors, such as flexibility and muscle strength; therefore,
this study may have underestimated the number ofparticipants with issues. Thus, more factors must be
considered in physical assessments in further research.

7. Study interpretation
Doctors and trainers must be aware of the physicaland mental conditions of their athletes, and adjust
treatment and training accordingly. Our multifaceted
condition-check study indicated that few athletes haveno physical or psychological issues, but the majority had
combined physical and/or psychological issues. Effective
conditioning requires an appropriate approach to theissues identified here, and the development of formal
guidelines to assist all in the process.

8. Study generalizability
Previous studies reported the occurrence of physicalor psychological issues in various athletic disciplines,
and revealed similar results. Hence, there is a need fora multifaceted condition-check and flexible approach toconditioning, which ought to be extended to collegiate
athletes across different sports.
Funding: This work received no funding.
Disclosure statement: The authors report no conflict ofinterest.
Data set availability: The data are not publicly
available due to restrictions on information release that
could compromise the privacy of research participants.
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Name:
Naruto Yoshida
Affiliation:
Department of Acupuncture andMoxibustion, Faculty of Health Care,
Teikyo Heisei University

Address:
2-51-4 Higashiikebukuro, Toshimaku, Tokyo 170-8445 Japan
Brief Biographical History:
2017- , Associate Professor, Teikyo Heisei University
2013- 2017, Lecturer, Teikyo Heisei University
2009- 2013, Assistant professor, Teikyo Heisei University
Main Works:• Yoshida, N., Kunugi, S., Konno, T., Masunari, A., Nishida,S., Koumura, T., Kobayashi, N., Miyakawa, S. (in press).
Differences in muscle activities and kinematics between
forefoot strike and rearfoot strike in the lower imb during 180°
turns. International Journal of Sports Physical Therapy.
• Yoshida, N., Takashima, N., Miyakawa, Y., Waki, H.,
Yamamoto, J., Kobayashi, N. (2019). Effect of change in heightand stability of feet on muscle activity during side bridge.
Japanese Journal of Athletic Training, 4(2): 147-153.
• Yoshida, N., Okuma, Y., Miyazaki, S. (2016). Effect ofacupuncture stimulation on muscle fatigue during the M-test
and Functional Movement Screen. Japanese Acupuncture andMoxibustion, 12(1): 24-31.
• Yoshida, N., Kunugi, S., Mashimo, S., Okuma, Y., Masunari,A., Miyazaki, S., Hisajima, T., Miyakawa, S. (2016). Effect offorefoot strike on lower extremity muscle activity and knee
joint angle during cutting in female team handball players.
Sports Medicine Open, 2(32).
Membership in Learned Societies:• Japanese Society of Science and Football• Japan Association of Handball Research• Japan Society of Acupuncture and Moxibustion• Japan Society of clinical sports medicine• Japanese Society of Physical Fitness and Sports Medicine

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