The important findings of this study are the following: (1) 50% of respondents believed that three back-to-back matches were the maximum amount that one should play, (2) 50% of respondents felt that there in/off season breaks were infringed upon by club or country, (3) 76% believe there should be regulations in place to protect them from these infringements on their breaks, (4) 48% felt that their opinions are not taken into account when the IMC scheduling is done, (5) 35% of respondents believe they sustained one injury due to match congestion while 20% believe they sustained multiple injuries due to match congestion, (7) 46% felt that due to match congestion and lack of recovery time, there mental health was negatively affected, (8) 46% preferred fewer but more extended international window periods, (9) 76% still prefer the traditional World Cup every 4 years, (10) 69% of respondents preferred the traditional 32 team World Cup squads, (11) only 14% felt that there was collaboration on load management between club and country medical staff.
A large proportion of respondents felt that fatigue from the lack of recovery time, their mental health, cognitive function and mood were negatively affected due to the congestion of the IMC. This study builds upon the available literature findings where players believe the congested fixture schedule has contributed to sustaining injuries and missing out on game time [6, 7, 9, 11, 13, 14, 16, 17]. However, the relationship between acute fatigue and cognitive performance needs further investigation in the literature [12, 18]. Half of the respondents in this study believed that three back-to-back games should be the maximum allowed. Other sports have shown a correlation between congested match schedules and injuries. The National Basketball Association (NBA) has shown a strong association between injuries, back-to-back games and away games (Gouttebarge et al., in 2019, investigated the negative effect on travel). Attention to the game schedule may reduce the incidence of injuries [19]. Field hockey (a multi-directional movement sport) has also shown a significantly increased risk of injury when scheduling games between twenty-four hours and three days after a fixture [20]. The football industry should be wise to realise these lessons from other sports, as fixture congestion may lead to a pending injury crisis within the international football environment.
While FIFA has recently strongly considered having a World Cup every two years, most respondents believe the current 4-year schedule is sufficient. A more regular World Cup competition (taking into account international qualifiers, travel and team match obligations) in an already congested IMC would certainly risk players from a mental, cognitive, injury, fatigue and performance perspective [16,17,18]. This probably explains why most respondents in this study believe they need to be protected from a regulation perspective to protect their health and well-being so they may continue to perform at optimal levels. Players may feel despondent, as half of the respondents believe their voices are not heard in IMC scheduling. This may further contribute to the negative effect on mental and performance health. A reduction in match congestion may lead to a lower incidence of injury, fatigue, cognitive and mental health effects, thereby maintaining performance health.
The upcoming FIFA World Cup in Qatar is also occurring at an unusual time in November 2022, i.e. midseason. This period is usually winter in the northern hemisphere and summer in the southern hemisphere. During this period, injury and mental health surveillance may reveal unusual patterns due to the midseason timing (effect on acute:chronic load) and prevailing weather conditions.
Communication of load monitoring when transitioning between club and country is vital to reduce the incidence of injury and maintain performance at both levels of play [21]. Respondents in the study confirm poor load monitoring communication between club and country medical staff.
The clinical relevance confirms and builds upon previous studies, suggesting that if players do not have optimal recovery time, it may affect them physically and mentally, exposing them to a higher rate of injuries and possibly mental health symptoms. This study expands on Gouttebarge et al.’s study by: (1) including players' opinions over more continental divisions with a larger cohort, (2) exploring ideal match load, (3) determining the acceptable frequency of World Cup events, (4) differentiating the negative impact of match congestion in relation to the effect on injury and mental health, (5) investigating communication between club and country regarding load and (6) acquiring players opinions regarding regulations and decision making in the IMC scheduling. A greater injury incidence would then mean that there will be less player availability which may affect team performance. Consequently, teams must have larger squads to allow for squad rotation. In light of high training and match loads, short recovery periods, and more possible injuries, teams will be spending extra financial resources on managing these physical injuries and any psychological issues.
Load monitoring communication between the club and country needs further exploration further. The authors propose a call for developing a standard template describing loads prior to National call-ups and upon return from National duty. Such a tool can assist in reducing injury incidence in light of a congested IMC. Repeating the questionnaire amongst the same cohort in future will be able to evaluate whether their opinions remain the same or change over time (taking the present IMC into perspective with uncertainty as to future IMC changes).
One of the limitations of this study is that more than half of the respondents have never played for their national team, so their opinion and perspective of some questions would only be from their observations of others and hear-say. However, they possibly play for teams competing in competitions dictated by the IMC. Another possible limitation, specifically regarding the number of respondents, may be that the questionnaires were distributed during a challenging part of the season. At this time, most leagues were moving toward the mid-season break. Players might feel pressured to perform on the field and not complete the questionnaires as the matches received their sole attention. Another limitation is that players may have had a hidden agenda regarding the IMC and saw this opportunity for FIFA to hear their voices since the majority felt their voices did not count. The purpose of this study was not to collect injury incidence or to determine injury rates (injuries/1000 h). Nevertheless, the data shows that players believe match congestion contributed to the increased rate of sustaining injuries.