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© 2000 American Orthopaedic Society for Sports Medicine

Football Injuries and Physical Symptoms

A Review of the Literature
Jiri Dvorak,* MD, and Astrid Junge, PhD

From the Schulthess Clinic, Zurich, Switzerland

ABSTRACT mated to be 10 to 35 per 1000 game hours (see Table 1).

Assuming one athlete plays on average 100 hours of foot-
Football is one of the most popular sports worldwide. ball per year (about 50 hours per player for a local team,
The frequency of football injuries is estimated to be up to 500 hours per player for a professional team), it is
approximately 10 to 35 per 1000 playing hours. The estimated that every player will incur at least one perfor-
majority of injuries occur in the lower extremities, mance-limiting injury per year. In view of the increasing
mainly in the knees and ankles; the number of head frequency of injury, the resulting primary and secondary
injuries is probably underestimated. The average cost costs, and, not least, the personal suffering of the injured
for medical treatment per football injury is estimated to players, analyses of risk factors are required as an essen-
be $150 (U.S. dollars). Considering the number of tial prerequisite to the development of prevention pro-
active football players worldwide, the socioeconomic grams. An excellent review of epidemiologic studies by
and financial consequences of injury are of such a Inklaar28, 29 pointed out that the current information con-
proportion that a prevention program to reduce the cerning risk factors and predictors of football injuries is
incidence of injuries is urgently required. For this rea- inconsistent and far from complete.
son, an analysis of intrinsic (person-related) and ex-
trinsic (environment-related) risk factors was under-
taken based on a review of the current literature. It was DEFINITION OF INJURY IN FOOTBALL
concluded that the epidemiologic information regarding
the sports medicine aspects of football injuries is in- No consensus regarding the definition of injury in football
consistent and far from complete because of the em- has yet been reached.28, 33, 47 In most studies concerning
ployment of heterogeneous methods, various defini- the incidence of football injuries, different criteria have
tions of injury, and different characteristics of the been used. This makes the direct comparison and inter-
assessed teams. The aim of this study was to analyze pretation of results difficult and at the same time is a
the literature on the incidence of injuries and symptoms possible explanation for the somewhat differing results.
in football players, as well as to identify risk factors for The most common criterion in the definition of an injury
injury and to demonstrate possibilities for injury is an absence from training or game(s) followed by the
prevention. need for medical treatment and the diagnosis of anatomic
tissue damage. This criterion, however, can be misleading
and is open to misinterpretation. Absence from training
and games is not only influenced by a very strong subjec-
Football is one of the most popular sports worldwide, with tive component but is also directly affected by the fre-
an increasing number of active players as well as specta- quency of games, the availability of medical treatment
tors. Currently, FIFA, the world governing body of foot- and, finally, factors such as the importance of the player
ball, unifies 203 national associations and represents and the expected outcome of the game.33 In some studies,
about 200 million active players, of which about 40 million football injuries are recorded based on insurance company
are women. records, which implies that the injured player was treated
Based on well-established epidemiologic studies, the in- by a physician or in a hospital.49, 54 This system probably
cidence of football injuries in adult male players is esti- leads to an underestimation of the incidence of less severe
injuries or symptoms due to overuse, which are not always
subject to medical treatment. The medical diagnosis may
* Address correspondence and reprint requests to Jiri Dvorak, MD, Spine seem to be an objective criterion, but it is also directly
Unit, Schulthess Clinic, Lengghalde 2, CH-8008 Zurich, Switzerland.
No author or related institution has received any financial benefit from the related to the availability of qualified physicians. The
research in this study. Council of Europe defined a football injury as an injury

S-4 Dvorak and Junge American Journal of Sports Medicine

occurring as the result of participation in official football activ- some studies, the incidence has been calculated per 1000
ities with one or more of the following consequences: reduction hours of football without specification as to whether these
in the amount of football activity, need for advice regarding 1000 hours were only competitive games or whether they
treatment, and adverse social or economic effects.69 also included training time.28, 33 In other studies, the in-
Closely related to the pitfalls and biases in the definition of cidence has been calculated for 1000 hours of games as
injury is the rational estimation of the degree of severity. well as for 1000 hours of training, but in each case using
Van Mechelen et al.68 suggested six criteria to account for the total number of injuries. When analyzing the risk
the degree of injury severity: type of injury, duration and factors leading to an injury, most researchers do not
modality of treatment, absence from training and playing, present the important differentiation between injuries oc-
work disability, structural changes and irreversible damage curring during games or during training. There are not
to the body, and costs related to the injury treatment. only methodological difficulties in calculating the inci-
Some of these criteria are described in epidemiologic dence of injury, but also other influencing factors, such as
studies.28 However, the degree of severity is almost al- age, sex, and the level of play, that have to be taken into
ways related to the duration of absence from training and account to compare the different studies.
participation in games. If absence from training and The overall analysis of injury rates in the different
games is used as the criterion to indicate the degree of studies results in an incidence ranging from 0.5 to 45
injury severity, it must be noted that absence may also be injuries per 1000 hours of practice and games.28 The in-
influenced by other factors, including psychological ones. cidence of injuries varies in different studies because of
It is not, therefore, an absolutely objective measure. differences in research design and characteristics of the
population. In adult male players, the incidence is about
INCIDENCE OF INJURY IN FOOTBALL 12 to 35 injuries per 1000 hours of outdoor games and 1.5
to 7.6 injuries per 1000 hours of practice (Table 1). In
Injury incidence is defined as the number of injuries oc- female players and adolescents, the incidence of injury
curring during a study period. Consequently, the inci- seems to be lower. In indoor football players, the incidence
dence of football injuries has most frequently been calcu- of injury seems to be higher.28 Table 1 provides an over-
lated based on the time period when there was a risk of view regarding the incidence of injuries in male outdoor
injury, that is, the hours during games and training. In football players based on relevant epidemiologic studies.

Epidemiologic Studies on the Incidence of Injury in Male Outdoor Football Players

No. of Injuries per 1000 hours (mean ⫾ SD)

Authors Population (age) Study period
players Games Practice Exposure

Hawkins and Fuller 23 108 Professional players 3 seasons 25.9 3.4

30 Youth players 3 seasons 37.2 4.1
Lüthje et al.38 263 Elite players (17–35 years) Season 16.6 1.5
Inklaar et al.30 75 Adolescents (13–14 years) Season 12.8
78 Adolescents (15–16 years) Season 16.1
79 Adolescents (17–18 years) Season 28.3
245 Adolescents (⬎18 years) Season 15.8
Arnason et al.3 84 Elite players (18–34 years) Season 34.8 ⫾ 5.7 5.9 ⫾ 1.1
de Loës12 350,000 “Young people” (14–20 years) 1987–1989 0.7
Kibler34 Adolescents (12–19 years) Tournament 2.4
Blaser and Aeschlimann10 90 Division leagues (16–42 Tournament 2.1 to 10.7
years) (different
Schmidt-Olsen et al.56 496 Adolescents (12–18 years) 1 year 3.7
Poulsen et al.48 19 Division 1 1 year 19.8 4.1
36 Series 3 & 5 20.7 5.7
Yde and Nielsen71 152 Adolescents (6–18 years) Season 5.6
Engström et al.21 64 Elite players 1 season 13 3
Ekstrand and Tropp20 639 Senior players (17–38 years) 1 year
135 Division 1 21.8 ⫾ 1.7 4.6 ⫾ 1.7
180 Division 2 18.7 ⫾ 1.7 5.1 ⫾ 1.7
(Ekstrand et al.18) 180 Division 4 (1980) 16.9 ⫾ 2.1 7.6 ⫾ 2.1
144 Division 6 14.6 ⫾ 5.9 7.5 ⫾ 5.9
Nielsen and Yde44 34 Division level Season 18.5 2.3
59 Series level 11.9 5.6
30 Youth (⬎16 years) 14.4 3.6
Backous et al.4 681 Adolescents (6–17 years) Summer camp 7.3
Hoff and Martin26 455 Adolescents (⬍8–16 years) Competition 7.4
Maehlum et al.39 1016 Adolescents (⬍12–18 years) Norway Cup 9.9
Schmidt-Olsen et al.55 5275 Adolescents (9–17 years) Tournament 16.1
Sullivan et al.58 931 Adolescents (7–18 years) Season 0.5
Nilsson and Roaas46 25,000 Adolescents (11–18 years) Tournament 14
Vol. 28, No. 5, 2000 Football Injuries and Physical Symptoms S-5

LOCATION AND NATURE OF INJURIES common in football than previously thought and that
acute head injuries may be the potential cause of long-
Football injuries affect mostly the ankle and knee joints, term neuropsychological changes.
as well as the muscles and ligaments of the thigh and Matser et al.40, 41 investigated chronic traumatic brain
calf.22, 28, 66 Inklaar28 concluded from his review of the injury in professional and amateur football players. Fifty-
literature that 61% to 90% of all injuries occurred in the three active professional football players from several pro-
lower extremities. Goalkeepers, however, have more head, fessional Dutch football clubs and 33 amateur players
face, neck, and upper extremity injuries than lower ex- from 3 regional league clubs were compared with a control
tremity injuries.6 Inklaar et al.30 found that the distribu- group of 27 elite athletes from noncontact sports. All par-
tion of injuries according to body part seemed unrelated to ticipants underwent neuropsychological tests proven to be
age-group distribution. However, more upper leg injuries sensitive to cognitive changes incurred during contact and
were sustained at a high level of play than at lower levels.
collision sports. The professional as well as the amateur
The most common types of injuries in football are con-
football players exhibited impaired performance in mem-
tusions, sprains, and strains. Youth players sustain more
ory and planning (professional players had additional im-
contusions and fewer overuse injuries than do senior play-
pairment in visuo-perceptual processing) when compared
ers. A higher percentage of strains has been registered in
with control subjects. Performance on these tests was
professional football than in senior amateur football.28
inversely related to the number of concussions incurred in
Most football injuries are traumatic, and the proportion
football40, 41 and to the frequency of heading the ball.41
of injuries caused by overuse varies from 9%3 to 34%.44
Among professional players, performance on the neuro-
Inklaar et al.30 reported that the distribution of traumatic
psychological testing also varied according to field posi-
and overuse injuries was not related to age-group distri-
tion, with forwards and defensive players exhibiting more
bution. However, in the senior age group more overuse
impairment.41 The authors concluded that participation
injuries were sustained at a high level than at a low level
in professional and amateur football may adversely affect
of play.
the aforementioned aspects of cognitive functioning.40, 41
Head injuries have been shown to account for 4% to 22%
There are only a few studies concerning football-related
of all football injuries.67 The effect of concussions and head
symptoms and secondary degenerative structural changes
injuries on neuropsychological impairment has been in-
vestigated by several authors.5, 11, 31, 40, 41, 57 Jordan et in former football players. Räty et al.50 studied the life-
al.31 designed a study to determine whether chronic en- time occurrence of musculoskeletal problems in former
cephalopathy occurred in elite active football players as a elite male athletes and found that former football players
result of repetitive heading of the football. A group of 20 had more back pain and knee pain than former long-
football players was compared with 20 age-matched elite distance runners or shooters. Roos et al.53 reported that
male track athletes. A battery of neuropsychological tests the prevalence of gonarthrosis was 15.5% among elite
was used to assess cognitive function, and MRI scans were former football players, 4.2% among nonelite players, and
also performed. Both the questionnaire analyses and MRI 1.6% among age-matched controls. The authors concluded
demonstrated no statistically significant differences be- that football, especially at an advanced level, is associated
tween the two groups. with an increased risk for gonarthrosis.
In a more recent study by Barnes et al.,5 137 young male Comparing 57 retired football players with a control
and female football players were evaluated. There were 74 group of men of the same average age and weight, Klünder
cases of concussion registered in 39 male players and 28 et al.35 found osteoarthritis of the hip joint more often in
cases in 23 female players. For the men, 48 (65%) episodes the football players (49.1%) than in the control group
resulted from collision with another player. Headaches, (26.3%). Lindberg et al.37 compared the occurrence of cox-
dizziness, and being “dazed” were the most common symp- arthrosis in 286 former football players with that in an
toms reported. The authors concluded that concussion re- age-matched control group (mean age, 55 years). Hip cox-
sulting from player-to-player contact was a frequent haz- arthrosis occurred in 5.6% of the former football players
ard in football. Head injuries incurred this way may exert and in 2.8% of the control group. Among 71 elite football
more of an influence on the published findings of physio- players, the prevalence of coxarthrosis was 14%, com-
logic and psychological deficiencies than routine heading pared with 4.2% in the age-matched control and nonelite
of the ball. The same research group analyzed 29 cases of players.37
concussion diagnosed over 2 years in 26 athletes.11 In the Roos52 concluded from his review of the literature on
majority of the cases (69%), concussion occurred during long-term sequelae from football that a long-term football
games. Several injury mechanisms were identified, the career seems to increase the risk for early development of
most common scenario being a collision with another play- osteoarthritis in the lower extremity. This risk was higher
er’s head (28%) or elbow (14%). Seven players (24%) were in top-level players. Football constitutes a risk for osteo-
hit in the head by balls kicked with full force at a range so arthritis in two different ways. First, there is the in-
close that the players were unable to react quickly enough creased risk for knee injuries in football, such as meniscal
to protect themselves. However, none of the concussions and ACL injuries; second, there is the factor of the exces-
resulted from intentional heading of the ball. The basic sive repetitive loading on the hip and knee joints that
incidence of concussion was 0.96 cases per team per sea- occurs in football. In elite football players, knee and ankle
son. Boden et al.11 concluded that concussion is more injuries seem to lead to a serious long-term outcome, but
S-6 Dvorak and Junge American Journal of Sports Medicine

uninjured players also have a higher risk of developing of football injury. Most authors have found that the inci-
arthritis than the normal population.36 dence of injury increases with age.4, 26, 27, 29, 42, 43, 56


Both mechanical and functional instability predispose
In 1981, Pritchett49 collected insurance company data re- athletes to sprains of the knee and ankle.29 Arnason et al.3
lated to injuries of high school football players. The aver- found that significantly more injuries occurred in knees
age claim cost was $127 (U.S. dollars) for injuries in 1976 with medial instability than in stable knees. Ekstrand and
and 1977. Relatively minor injuries, such as sprains, Gillquist15 reported that three players who had anterolat-
strains, and abrasions, accounted for 76% of all injuries eral rotatory instability (positive pivot shift sign) detected
but only 49% of all costs. Lower extremity injuries ac- on examination sustained a knee injury in the following
counted for more than one-half of all injuries and costs. year and had to give up football permanently.
De Loes13 analyzed 571 injuries occurring in 28 differ- Ankle sprains have also been shown to occur more fre-
ent sports. The overall average cost per injury was $335 quently in players with clinical instability.15 Players with
(U.S. dollars). Individual sports such as motorcycling and abnormal stabilometric values run a significantly higher
downhill skiing were by far the most costly. The most risk of sustaining an ankle injury during the following
expensive of the team sports, ranking only fifth, was hand- season than do players with normal values.64 Only Arna-
ball, followed by football. The average individual cost of son et al.3 found no difference in the number of ankle
the 241 football injuries assessed was calculated as being sprains between ankles with lateral or anterior instability
$188 (U.S. dollars) (SD, $313). and those that were stable.
Ekstrand et al.17 showed that an injury reduction rate
of 50% to 70% might be possible if prevention programs Muscle Strength, Tightness, and Asymmetry
were implemented. The effect of such a reduction would be
considerable in view of the enormous medical costs and Ekstrand and Gillquist15 reported that players who sus-
the secondary costs involved (loss of playing or working tained knee sprains that were not due to collision had
days). Inklaar28 concluded from his review that, on aver- reduced muscle strength in the injured leg. No other
age, a football player suffers one injury per year. A con- strength differences between injured and uninjured play-
servative estimate of the average primary medical costs ers were found in this study. Inklaar29 has found a corre-
associated with one football injury is $150 U.S. dollars. lation between tight muscles and strains of the adductor
There are approximately 200 million active players regis- muscles. Significantly more players with muscle tightness
tered with FIFA; simple multiplication indicates that the (N ⫽ 34) sustained a muscle rupture or tendinitis than did
primary medical costs associated with football injuries is those with normal flexibility (N ⫽ 10). The 13 players who
$30 billion U.S. dollars per year. There are no reliable had rupture of the adductor muscles or tendinitis showed
prospective epidemiologic studies, but this estimate can significantly lower ranges of motion in hip abduction. No
probably be considered realistic, although it does not in- significant influence of range of motion was found with
clude the costs associated with the loss of competition or regard to hamstring muscle strains or knee and ankle
working days. Of course, this estimate remains hypothet- sprains.15
ical as the costs of medical treatment differ in different Muscle asymmetry seems to contribute to the risk of
countries and are probably much lower in countries where injury in football players. Agre and Baxter1 reported that
medical services are not as well developed as they are in one player with a side-to-side difference in hip abduction
the countries where the studies have been performed. of 9° and three of four players who had side-to-side differ-
ences in hip flexion of 6° or greater were subsequently
CAUSES OF FOOTBALL INJURIES injured. Ekstrand and Gillquist15 found that the strength
quotient for the injured/uninjured legs of players with
In general, a distinction has been made between so-called noncontact injuries was significantly lower than the right/
intrinsic (person-related) and extrinsic (environment-re- left quotient in uninjured players.
lated) risk factors.28, 60, 68 The intrinsic risk factors are
related to the individual biological or psychosocial charac- Body Mechanics
teristics of a person, such as age, joint instability, muscle
strength, muscle tightness, muscle strength asymmetry, Watson70 investigated possible relationships between the
previous injuries, adequacy of rehabilitation, and psycho- incidence of injuries and the existence of defects in “body
social stress. Extrinsic risk factors relate to environmen- mechanics” in players of various types of football. Injuries
tal variables such as the level of play; exercise load were recorded prospectively over a 2-year period. A stan-
(amount of competition and practice); amount and stan- dardized set of examinations employing photogrammetric
dard of training; position played; equipment such as shin techniques was used to assess 52 subjects. It was found
guards, taping, and shoes; playing field conditions; rules; that football players who suffered from ankle injuries had
and foul play. Both intrinsic and extrinsic factors can lower scores for ankle mechanics than did uninjured play-
partially influence each other and are therefore not inde- ers. Knee injuries were found to be associated with a
pendent of each other. Age can also be a factor in the cause higher degree of lumbar lordosis and the presence of sway
Vol. 28, No. 5, 2000 Football Injuries and Physical Symptoms S-7

back. Subjects who suffered from muscle strains had a The relatively high percentage of reinjury in football
higher incidence of lumbar lordosis, sway back, and ab- suggests inadequate rehabilitation and incomplete heal-
normal knee interspace. Back injuries were associated ing as a risk factor.29 Nielsen and Yde44 found that in 59%
with poor shoulder symmetry, scapular abduction, back of reinjuries the players had not completely recovered
asymmetry, kyphosis, lordosis, and scoliosis. In general, from a previous injury. Ekstrand and Gillquist15 reported
Watson found that the incidence of ankle, back, knee, and that players who sustained moderately serious or major
muscle injuries was influenced by the presence of a defect noncontact knee sprains had usually suffered a previous
of body biomechanics. These results suggest that interven- knee sprain with subsequent persistent mechanical insta-
tion programs to improve body mechanics might help re- bility. Overall, they attributed 17% of all injuries to inad-
duce the incidence of sports injuries in football players. equate rehabilitation of the previous injury. The analysis
of injury sequences revealed that minor injuries were of-
Psychological Factors ten followed by a major injury.15, 16 One-third of the mod-
erate or severe injuries occurred within 2 months after a
Several empirical studies have demonstrated the influ- minor injury.16
ence of psychological factors on sports injuries.2, 32, 60 How-
ever, only one article addresses this issue particularly in Level of Play and Position on the Field
relation to football.61 Although these studies are difficult
to compare because of the different methods employed, the Studies regarding injuries associated with different skill
results generally agree that life-event stress increases the levels have produced contradictory results. Inklaar et al.30
risk of a sports injury.32 From the numerous psychological reported a higher injury incidence for higher levels of play
attributes that have been investigated in relation to sports in four different age groups. Nielsen and Yde44 found the
injuries, only competitive anxiety has demonstrated any injury rate during games was highest at the division level
association with injury. A typical personality profile of an and lowest at the series level, whereas during practice, the
athlete likely to be injured does not exist. However, some outcome was the reverse. The same distribution was ob-
studies have shown that injured athletes demonstrate a served in the group investigated by Ekstrand and Tropp,20
lack of caution and an adventurous spirit. It appears that but the authors stated that the total incidence of injury
mental performance has been largely neglected in the was the same across differing levels of skill. Bjordal et al.9
past, although Taimela et al.61 showed that a prolonged showed that the rate of ACL injuries gradually decreases
reaction time was an important predictor of injury in at lower levels. Blaser and Aeschlimann10 reported that
football. the highest frequency of injury was seen in the lower
leagues. Poulsen et al.48 found no difference in the injury
Previous Injury and Inadequate Rehabilitation rate per 1000 hours of practice or games between high-
and low-level football players.
Previous injuries and inadequate rehabilitation are the Although most authors have stated that the field position
most important and well-established intrinsic risk factors played does not influence the injury rate,16, 21, 24, 26, 38, 44
for future injury.3, 14 –16, 20, 44 Nielsen and Yde44 reported Hawkins and Fuller25 found that defenders had a greater
that in 42% of injured players there had been an injury of risk of injury than other players. Other studies have
the same type and location during the previous year. In shown that goalkeepers’ injuries occur mostly in the upper
elite Belgian football players, 30% of sprains and strains limbs.6, 51
were reinjuries of the same type and location.29 Arnason
et al.3 stated that the frequency of reinjury was high Amount and Standard of Training
(35%), with 44% of muscle strains and 58% of ligament
sprains being registered as reinjuries of the same type and Arnason et al.3 showed that teams that had the longest
at the same location. training period registered significantly fewer injuries dur-
Ankle sprains have been shown to be more common in ing the season. Teams with a higher-than-average num-
players with previous ankle sprains.15 Arnason et al.3 ber of training sessions sustained fewer injuries. A high
found that 9 of 13 ankle sprains (69%) in their study were practice-to-game ratio seems to be advantageous.18 Ek-
in players with a history of previous sprain. Nielsen and strand and Gillquist15 attributed 6 of 256 injuries to a lack
Yde44 reported that all players who sprained an ankle of training.
while running had a previous history of ankle sprain. Agre and Baxter1 showed that an absence of muscle
Ekstrand and Tropp20 calculated a 2.3 higher risk of ankle strain injuries appeared to be directly related to the initi-
sprain in players who had previously sustained ankle ation of a controlled warm-up and stretching program. In
sprain. Only Tropp et al.64 reported that players with a the study of Ekstrand et al.,18 all seven quadriceps muscle
previous ankle joint injury did not have a higher risk of strains affected players on teams in which shooting at the
future injury compared with players with no previous goal occurred before warm-up.
injury. Their stabilometric recordings of 25 football play-
ers showed that an ankle joint injury did not result in Equipment
persistent functional instability65; nonetheless, such in-
stability, per se, did increase the risk of future ankle joint Failure to wear shin guards has been shown to notably
injury.64 increase the proportion of leg injuries.4, 8, 29 In two studies
S-8 Dvorak and Junge American Journal of Sports Medicine

by Ekstrand and Gillquist,15, 16 all traumatic leg injuries In the 1994 World Cup, 29% of all injuries resulted from
occurred in players who wore inadequate or no shin foul play as judged by the referees.25 Players have stated
guards. that fouls are in some way responsible for 25% to 33% of
A significant difference has been demonstrated in the all injuries.38, 44 Referees have considered that 23% to 28%
ankle sprain rate of players using ankle tape compared of all traumatic injuries are caused by the violation of
with those not using it.17 In a prospective study, the existing rules.15, 21
preventive value of special ankle braces has been prov-
en.63 However, stabilometric recordings of players with
and without ankle taping showed that taping did not CONCLUSIONS
influence the stabilometric values.65
Inklaar28, 29 concluded that the epidemiologic information
Surve et al.59 showed a fivefold reduction in the inci-
regarding the sports medicine aspects of football injuries
dence of ankle sprains in football players with previous
is inconsistent and far from complete. This statement is
ankle sprains using a semirigid orthosis compared with
also valid in view of more recent studies. More research is
the nonbraced group. Based on their review of the litera-
needed to identify high-risk groups and variables that
ture, Thacker et al.62 recommended that athletes who
may predict injuries within these subgroups. Such stud-
have suffered a moderate or severe sprain should wear an
ies should include uniform definitions of injury and
appropriate orthosis for at least 6 months to prevent a
should be based on sound epidemiologic and method-
recurrent ankle sprain.
ologic principles.
Shoe-surface contacts are important to football, and fric-
tion resistance must therefore be kept to a minimum.19
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