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In 2023, the Saudi Professional League, known as the Roshn Saudi Pro League (RSL), garnered significant global attention due to its successful acquisition of high-calibre football players worldwide. This transformation was marked by the arrival to the Kingdom of Saudi Arabia (KSA) of football icon Cristiano Ronaldo in early 2023, a move that signalled the league’s ambitious intentions.1 In July 2023, the surprises continued to unfold, with the league securing the services of Ballon d'Or 2022-winner Karim Benzema,1 and shortly after (ie, August 2023), the Brazilian superstar Neymar Da Silva Santos Junior, who joined his new Club with a staggering value of €90.00 million.1 These monumental signings have propelled the overall market value of the RSL to an impressive €906.85 million.1 However, as the RSL continues to attract football’s iconic players, it is imperative to consider the unique and challenging environmental conditions of KSA/the Middle East. Many players are accustomed to milder European climates. They will now have to adapt to the extreme heat, high humidity and dust that characterise the Middle East environment for several months every year. These conditions are not only a discomfort 2but also pose significant physiological and health challenges requiring meticulous attention and management.2
Ensuring the health and well-being of elite footballers is a responsibility that extends beyond the players themselves to the supporting medical and technical staff. As the RSL continues to rise in stature, it is incumbent on all stakeholders to prioritise players’ health and safety, safeguarding the league’s reputation and evolution. In this context, this editorial aims to explore the multifaceted challenges posed by the extreme climatic conditions of the Middle East, the potential health risks for players and the strategies that medical and sports science teams should employ to mitigate these risks.
Navigating the multifaceted challenges of elite football in KSA
As outlined in figure 1 and table 1, the challenging stressors that threaten the newly recruited players range from the pathophysiological responses to hyperthermic conditions and high mechanical load, to the mental health implications of cultural transition.3 It is imperative for the healthcare staff supporting these players to adopt a comprehensive, evidence-based approach, (1) not only addressing the immediate risks of heat-related illnesses and overuse injuries but (2) also proactively managing the mental health and well-being of players and their families as they adapt to a new and markedly different professional and personal landscape.
Optimising performance and health in extreme climates: a comprehensive approach for elite soccer players
Elite soccer performance places diverse bioenergetic demands on players, involving the phosphagen system, glycolytic pathway and oxidative metabolism.2 Fatigue management and recovery strategies are critical due to high-intensity efforts and congested fixture schedules in constraining conditions. Due to the extreme climate, poor air quality and dusty/sunny conditions can pose respiratory challenges, vitamin-D deficiency issues and implications for players’ mental well-being.4 Players face significant thermoregulatory demands in extreme heat/humidity. Efficient heat dissipation mechanisms, such as sweating and increased skin blood flow, are essential to maintain core body temperature.5 Hydration and electrolyte balance are critical to prevent heat-related illnesses. Acclimatisation strategies involving gradual exposure to heat and humidity are, therefore, key for the players with a specific focus on newly recruited ones.5
Elite players are subjected to intense physical and psychological strain, increasing the risk of hypohydration/dehydration, heat-related illnesses and injuries. Nutritional and hydration challenges are complex, especially in hot environments. Psychological stressors, including cultural adjustments and potential separation from family and friends, can affect the players’ mental health and performance.6 Each player’s response/adaptation to these conditions and demands is unique, influenced by genetics and pre-existing health conditions, deserving each an expert individualised approach.6
A call for action
To optimise players’ health in the constraining Middle East environment, a multidisciplinary approach should be considered: regular medical surveillance and monitoring, structured heat acclimatisation programmes, personalised nutrition and hydration strategies, psychological support services, evidence-based recovery and rehabilitation protocols and eventually environmental modifications when applicable, such as scheduling training/matches during cooler times and modifying facilities to provide shade and cooling systems. In this regard, education and clear communication among all stakeholders are paramount.
This is a call for action to implement comprehensive heat policies grounded in scientific evidence in challenging environments in Middle-Eastern countries like KSA. These policies and guidelines should specify fair protocols for rescheduling or cancelling matches based on objective environmental measures (Wet bulb globe temperature and air quality index, among others) or religious and cultural considerations like Ramadan and prayer times.7 Enhanced medical support and emergency preparedness, including regular drills and updates on best practices, are also paramount.8 Investment in research to study the unique challenges players face during and after their football career should be considered. Players shall be educated and empowered to communicate their needs and concerns with their direct technical and medical supporting staff.8 Collaboration between clubs, governing bodies, healthcare professionals and researchers is vital, as is advocacy for players’ welfare to engage policymakers and the broader public in support of necessary changes.
The 2023 surge in the RSL is a monumental step for football in KSA and the Middle East. However, bringing a profound responsibility to protect the health and performance of the players. This editorial emphasises the urgent need for research and evidence-based interventions tailored to the unique challenges of elite football in extreme conditions. During this exciting new football chapter, KSA can set a global example in player health and safety. We believe this can efficiently be done with Middle Eastern international collaboration with neighbouring countries, merging experiences for the good of Middle Eastern football.
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Twitter @IDergaa, @HHHMMBENSAAD, @DrJuanSports, @ProfChamari
Contributors ID: conception and design. ID, HBS, AEO, MK, JDPD and KC: analysis and interpretation of the data. ID, HBS, AEO and KC: drafting of the paper. ID, HBS, AEO, MK, JDPD and KC: revising it critically for intellectual content. All authors gave their final approval to the version that will be published.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.