The elite male amateur football medical staff’s perception of the current football boots market—a survey-based study of UK academies

Abstract The premium football boot is commonly only designed, tested, and manufactured for adult male players. Footwear worn by academy players is therefore not designed with growing athletes in focus. The study objective was therefore to assess the medical staffs’ perception of football boot fit and their interactions with player’s football boots. Medical staff from academy male players from elite category 1 and 2 football academies in the United Kingdom (UK) were surveyed using an validated online survey. Descriptive analysis and thematic analysis of the open ended question were conducted. A total of 49 responses were received of which five responses were removed as they did not meet the inclusion criteria. Only one responder reported no complications with football boots for their academy players. The most reported area of concern in relation to players complain of pain/discomfort and/or fit in their football boots was the heel region (76%). Common concerns included blisters/corns/rubbing, sizing issues, adaptation issues with frequent change of boots, and players prioritizing aesthetics over fit and comfort. Education of players was also desired. The findings of this study highlight the desire for tailored footwear education and assessment programmes. The study also highlighted key concerns about injuries, fit, and performance not currently supported by research.


Introduction
The premium football boot is commonly only designed, tested, and manufactured for adult male players. Modern football boots are flexible, lightweight, and designed with multiple outsole (stud/cleat) options to match the playing surface type. Innovative materials allow for very thin uppers to improve 'feel' for the ball. However, there are downsides to modern designs, such as minimal protection from injury and comfort issues (Jastifer et al., 2017;Nunns et al., 2016). Whether these performance features are satisfactory for academy aged players is currently not well researched, however, speculations on areas, such as varying performance, comfort, and fit, and injury prevention requirements challenges the assumption that adult male designs are optimal for other football populations.
The importance of fit is especially relevant in football boots as the design is tight compared to many other sports footwear designs (Santos et al., 2001). This is evident as the plantar pressure and ground reaction forces experienced in football boots have been shown to be higher compared to running shoes (Santos et al., 2001;Smith et al., 2004). Tight fitting is, however, desired by players (Hennig & Althoff, 2012) which, together with a normalized attitude towards having to 'break in' football boots before comfort is achieved, makes it challenging to educate players on the importance of ensuring comfort and fit. However, boots that fit too tight can increase plantar pressures due to decreased boot-foot contact area, while also compressing foot structures. Hence discomfort or pain is common among football players (Santos et al., 2001). Performance impairment related to discomfort has also been shown in the literature for senior male players (Okholm Kryger et al., 2021). This concern has not been assessed in academy players, but it can be assumed that similar trends would be seen.
Final foot length in boys is commonly achieved at the age of 13-15 years (Cheng et al., 1997;Maier & Killmann, 2003;Walther et al., 2005) with foot shape also changing over time (Barisch-Fritz & Mauch, 2021) making it challenging to ensure optimal (and long-lasting) football boot fit in younger academy players.
Foot injuries have been shown to vary between 0.8 and 6.5 incidences per 25-player squad per season in U9 to U19 elite male academy football players (Materne et al., 2021). The third most common foot and ankle injury type for this playing group was reported as apophyseal osteochondrosis injuries (prevalence ¼ 6.9% of all foot and ankle injuries), which are common growth-related foot injuries (Gillespie, 2010). As footwear is considered a potential risk factor for injury, footwear interventions are commonly introduced as part of injury management strategies (Achar et al., 2019;Gillespie, 2010;Launay, 2015).
The first and fifth metatarsal are found to be particularly susceptible to injury and discomfort location. Stud/cleat length or arrangement on the outsole can increase plantar pressures in football boots (Thomson et al., 2018). It is important to achieve full stud penetration on the playing surface to decrease high regional plantar pressures that may give rise to an increased risk of metatarsal stress fractures (Kirk et al., 2007;Miyamori et al., 2019;Nunns et al., 2016). However, as we currently use outsole definitions matching senior male research, it is questionable whether these definitions match academy players' loading, desired traction generation, and requirements for injury protection.
Player expectations and desires for football boots have been researched in both senior male and female football players over a decade ago (Hennig, 2011), whilst no research is available on academy players. Instead of surveying the players themselves, this study aimed to focus its attention on the medical staff within male elite academy setting in the UK. This approach was chosen to gain a medically educated opinion and an overview of the general image rather than the player's more individual viewpoints. Medical staff also have the potential to influence behaviour and football boot selection (Dhillon et al., 2020), and obtaining their perceptions may have the ability to highlight the areas that need modifying in the male academy football boot market. The responses are not solid evidence of quantifiable issues, however, the qualitative data reported can be used to highlight directions for future quantifiable research within the field of academy football boots. A research topic largely neglected in comparison to football boot designs for senior male players.
Therefore, the objective of the study was to assess the medical staffs' perception of football boot fit and their interactions with player's football boots.

Methods
This study followed the Checklist for reporting Results of Internet E-Surveys (CHERRIES; Eysenbach, 2004). This was a cross-sectional survey surveying a convenience sample. Ethics (No. QMREC2018/48/042) were approved by the Queen Mary University of London ethical committee and informed consent was taken from each participant before beginning the questionnaire. A university approved and protected survey database and drive were used for surveying and storing responses.

Questionnaire development
The questionnaire was developed using the following steps: (i) construct determination, (ii) item generation, (iii) survey design, and (iv) content analysis (Malliaropoulos et al., 2014). Questionnaire completeness was checked by authors manually. Questionnaire usability, relevance, and content validity were checked by authors and by members of an English Tier 1 academy club medical team acting as external experts. The study was further piloted on two English Tier 1 academy club medical team members. No amendments were made after piloting. The questionnaire consisted of a demographics section (two single option answer questions and one open textbox answer question), a player complaint section (one binary answer question, one single option answer question, and two open answer questions), a boot manipulation section (two binary answer questions, one single option answer question, and two open answer questions), and a market satisfaction section (one binary answer question and one open answer question). Survey questions were a mix of mandatory and optional questions. These were not randomized or alternated. The full questionnaire can be accessed in Supplementary Appendix 1.

Inclusion criteria
Participant inclusion criteria included medical staff from male academy players from elite category 1 and 2 football academies in the United Kingdom (UK). Exclusion criteria excluded those who could not read or write in English.

Distribution
The survey was developed and distributed using Jisc Online Survey (Online survey, Jisc; Bristol, UK). Participants were recruited from April 2020 to July 2021. Recruitment occurred via email distribution to all English Premier League clubs as well as via Twitter using author and The Football Medicine and Performance Association (FMPA) accounts. The nature of distribution prevented an exact response rate being calculable. The survey was shared as an open survey, which was voluntary for people to participate in (no login was needed). No incentives were offered to participants.

Data analysis
Descriptive analyses using counts and percentages were conducted within Microsoft Excel (version 1652, Microsoft Corporation, Redmond, WA, USA). Thematic analysis of the open ended question of the survey asking participants was conducted using Braun and Clarke's six step model (Braun & Clarke, 2006). Analysis was approached inductively by tagging each response with applicable themes. These were then compared and clustered to form categories.

Demographics
A total of 49 responses were received of which five responses were removed as the responders did not match the inclusion criteria (one response from an academy director, four responses from academy coaches). The majority of responses came from physiotherapists (67%) and majority 57% of responses came from people with more than 5 years of experience in elite academy football, whilst only one had less than a year of experience (Table 1).

Issues experienced with football boots amongst academy players
The most reported area of concern in relation to players complain of pain/discomfort and/or fit in their football boots was the heel region (76%), followed by the hallux (50%), and 5th metatarsal (33%; Figure 1).
Only a single member of staff reported that 'nil' problems were encountered with their academy player's football boots, whilst everyone else reported multiple problems (Table 2). Commonly encountered problems included blisters/corns/rubbing (n ¼ 16; Table 2; Figure 2). These were frequently in relation to other problems, such as fitting issues (n ¼ 24) and adaptation issues with frequent change of boots (n ¼ 7) seen through comments, such as 'Players tend to prefer tight fitting boots which cause corns and rubbing' and 'Severe blisters especially when new' (Table 2). Other problems experienced included prioritization of aesthetics (n ¼ 5), low support (n ¼ 16) poor boot/stud selection to weather (n ¼ 4), surface (n ¼ 5), etc. (Table 2).
A large proportion of staff (n ¼ 33; 69%) reported players having their football boots manipulated. These manipulations were performed by a range of people, including staff members (n ¼ 22; 45%), third party (n ¼ 20; 40%), player themselves (n ¼ 12; 24%), brand manufacturer (n ¼ 5; 10%), and unknown (n ¼ 1; 2%). The responders themselves indicated in 31% of cases that they manipulate or customize football boots for any of their academy players. The most reported modified component was the insole (n ¼ 20; 61%), followed by adapting the outsole including both stud type, e.g. 'changing moulds for studs', removal of studs, e.g. 'stud removal', or adding a carbon fibre plate, e.g. 'the addition of a carbon fibre support to the 5th metatarsal area for one player' (Table 3).
Whilst many modifications of boots were seen, only 21% of staff declared that they were consulted by players regarding their football boots. The advice sought included boot modifications, injury risk/management, fit/size, support, surface fit, aesthetics, performance, or general issues (Table 4).

Satisfaction with the football boot market
A total of 71% stated they were satisfied with the current football boot market for academy players, whilst 29% were not. The reasons for dissatisfaction most commonly included a concern about compensatory focus on aesthetics (n ¼ 5) as stated by a participant as 'Football boots appear to be more worried in how the look and feel to a player than any consequences they may have over safety and protection' ( Table 5). More specific academy focussed concerns included lack of focus on foot growth within the design (n ¼ 2), lack of player and parent education from manufacturers (n ¼ 3), and costs (n ¼ 1; Table 5). One participant also highlighted the desire to have customized boots available 'I believe boots should be custom fit to the individual' (Table 5).

Discussion
The purpose of this study was to assess medical staff's perception of football boot fit to gain an insight into the issues they experience with their made academy player's football boots, the modifications they make to football boots, and their overall satisfaction with the current football boot market for male academy players. This paper was the first to review the satisfaction of football boots for academy soccer players and the first to utilize medical staffs' opinions rather than the players themselves.

Concerns about football boot fit
Players frequently changing their football boots was a recurrent theme that presented. Medical staff found players did not allow for a 'break-in' period which caused blistering and abrasions, 'transitioning into new boots too quickly, leading to blisters'. Although blisters may seem a small and irrelevant issue for an elite level soccer player, they can become problematic (Taylor et al., 2006), and cause <1 year 1 2 1-2 years 5 12 2-5 years 12 29 5-10 years 16 38 More than 10 years 8 19 Figure 1. Foot regions of concern in relation to players complain of pain/discomfort and/or fit. Note: 'Other' was reported as Achilles tendon region. Blisters/corns/rubbing 16 "The regular change in boots leads to occasional boot related foot reactions ex blisters" "Blisters" "Blisters" "Blisters" "Blisters" "Blisters and skin abrasions" "Players tend to prefer tight fitting boots which cause corns and rubbing." "Severe blisters especially when new." "Blisters at heel and on toes" "Transitioning into new boots too quickly, leading to blisters" "Blistering from poor fitting." "Severe blisters especially when new." "Skin complaints, i.e. blisters, corns" "The rear heel of the boots can sometimes cause issues with blisters .. due to plastic fancy bits rather than size .." "Some players have also suffered from posterior heel discomfort due to friction of certain boots design" Adaptation issues with frequent change of boots 7 "The regular change in boots leads to occasional boot related foot reactions ex blisters" "Insufficient consideration from the player for a period to break the boots in and frequent switching of boots." "Issues within the initial stages of use following change of style/type of boot" "If boots are new they are sometimes not worn in properly before matches, resulting in heel pain" "Buying new boots and wearing them straight to game without trail." "Transitioning into new boots too quickly, leading to blisters" changing of style of boot" "Issues within the initial stages of use following change of style/type of boot" Prioritising aesthetics 4 "Depending on the brand but overall I feel that boots are more about Aesthetic rather that comfort." "Much of the time the players are choosing boots that look good (particularly lace-less boots) and these choices are usually at the detriment of their foot support/ functional allowance." "Look v comfort" "Cosmetics above function." Fit issues Adaptation to growth 3 "Rapid change in players foot size therefore fit." "Sometimes too small if their feet are growing and they haven't got a new pair yet, mainly causing toe pain." "Growth related, i.e. severs" Tight fit 5 "Too rigid/ snug fitting" "Narrow fittings causing discomfort." "Tightness around forefoot" "Narrow boots: compression of toes" "Too tight, [ … ] Poor fitting in width." General fit issues 6 "Poor fitting," "Poor fitting" "Fit" "Fit" "Blistering from poor fitting." "Ill-fitting" Sizing issues 10 "Too small a lot of the time" "Players choose sizes that are too small and get foot injuries" "Players wearing boots that are too small for economic and style reasons." "Probably some of them buying [ … ] wrong size" "Wearing boots too small for them-they do not admit any ailment/injury with regard to this, nor have I seen cases of direct injury from such, but it is something that concerns me" "Players choose sizes that are too small and get foot injuries" "Issues with choice of sizing" "Players not wearing correct size -commonly too small" "Size selection (playing in boots that are too small)" "Too small/large" Poor boot/stud selection Weather 4 "Player's not wearing the correct boots for certain weather conditions." "Not wearing appropriate boots (i.e. not wearing studs in rain or bringing no second pair in case change of weather)." "Incorrect boot type worn (e.g. moulds in wet conditions)" (continued) significant issues for medical staff as found in our results. Each material, however, has a different break-in period and may differ between football boots and the brand (Goonetilleke et al., 2000;Olaso Melis et al., 2016). Football boot fit is also a concern for medical staff surveyed. Over half (55%) of staff surveyed reported fit related issues to be most frequently encountered. Sizing issues were most common with staff reporting 'players choose sizes that are too small and get foot injuries' and 'Narrow fittings causing discomfort'. Issues with children's footwear sizing has previously been reported in literature and is no different in a sport setting (Haley et al., 2019). Staff found players not only presented with injuries and areas of discomfort relating to fit but also experienced blistering, 'Blistering from poor fitting'. As a direct comparison, running footwear have been widely studied over the last decades (Sinclair et al., 2016) with a large research and marketing focus on comfort (Meyer et al., 2018;Mohr et al., 2017). Football boots, on the contrary, have predominantly received a performance focus in research and marketing. Still today football boots Problem N Example quote "Wearing the wrong type, e.g. soft ground molds to a game on grass when it is wet" Surface 5 "Not wearing the appropriate cleat for specific surfaces. Stud shapes, round and larger tend to give best traction on AG." "Poor selection by the players, players wearing boots on inappropriate surfaces" "Wrong type of studs for surface" "Wearing the wrong type, e.g. soft ground molds to a game on grass when it is wet" "Wrong studs for different surfaces." Switching 1 "Poor selection by the players, [ … ] players switching boots between training / matches" General 1 "Stud placement and stud type" Difficult to handle in medical situations 2 "Difficulty taking on/off in medical scenario, at times, requiring to be cut off (especially Nike hyper venom-type sock boots)" "Boots with no laces are difficult to remove when players have serious injuries and require pitch side assessment" Additional design elements 2 "Heel pain due to stiff soles" "Insoles not suitable." Outsole stiffness/stud placement/shape/type 1 "Reduced rigidity base of boot" Costs 3 "Parents can't afford to continually buy boots for growing kids" "Players wearing boots that are too small for economic and style reasons." "Probably some of them buying cheap model" Sponsorship 2 "Can be dictated by a player sponsorship" "With the majority of players, they get sent the latest boots to wear every 6 weeks, with no individuality. Only the top players who can afford to be more vocal would ask about changing their boots. So we see frequent variation in boot type, design etc." Low support/injury aggravation/protection 16 "Ankle/foot tendinopathies due to excessive load through certain areas when in specific boots due to position if foot when in contact with ground. Severes due to poor heel padding. Contributing factor to injuries further up the chain due to foot positioning in heel strike, mid stance and tie off phases." "As a result, they are found, at times, to effect the foots ability to release the 1st MTJ in gait which Has a knock on effect further up the kinetic chain at the ankle/knee/hip and back." " a [ … ] offer little protection to direct impact" "Lack of protection from contact injuries" "Achilles tendon pain" "Players choose sizes that are too small and get foot injuries" "Lack of support to foot, reduced shock absorbance/transfer of load" "Stress responses around metatarsal and tarsal bones" "[ … ] and also offer little protection to direct impact" "Inadequate support" "No foot protection" "The stud under the big toe can often cause irritation to the great toe sesamoid bone and hard insoles near the heel can cause aggravation of growth-related heel issues" "Ligament injury due to instability" "Lack of foot support: arch/mid foot" "Some Boots too lightweight, not giving enough stability to foot" "Poor support" Material quality 3 "[ … ] reduced quality materials" "Material is too thin" "Reduced quality materials" Mechanics 2 "Mechanics" None 1 "Nil" are expected to be 'broken in'. Something athletes would not expect of other sports footwear, including running shoes. One might think given the innovation and money in sports technology, including football boot designs, that blistering would no longer be as prevalent an issue as reported by the male academy medical staff.

Concerns about football boot pressure and loading
Medical staff raised their concerns with regards to the lack of protection in players football boots and their potential to increase the forces going through the player's foot, 'Stress responses around metatarsal and tarsal bones'. Staff also reported to adapting players boots in an attempt to reduce these forces 'Stud configuration changed in attempt to offload 5th metatarsal'. To continue the running shoe analogy, football boots have significantly greater forces and impact loading rates compared to running shoes when running due to the studded outsole and minimalistic thin soleplate and insole in football boots (Santos et al., 2001;Smith et al., 2004). Male academy players and runners both cover large running distances (Abbott et al., 2018;Wass et al., 2020). Running with higher plantar forces and pressures exposure can give rise to impact injuries, such as stress fractures, in particular the 5th metatarsal when carrying out football-specific tasks (Thomson et al., 2018). Stud shape and positioning may also play a role in increasing the plantar pressure on the lateral border of the foot and therefore increasing players risk of stress injuries in this area (Bentley et al., 2011;Nunns et al., 2016;Silva et al., 2017). Modern football boots are lightweight with little protective elements and when placed on a skeletally immature foot going through high loads may give rise to increased injury rates (Nunns et al., 2016). Academy players should therefore take great care when selecting their football boots to ensure maximum protection and adequate stud configuration.

Concerns about plantar pressure and associations with Severs' disease
Additionally, Calcaneal apophysitis (Severs' disease) was a concern frequently encountered by staff as reported in the survey, e.g. 'Severes due to poor heel padding' and 'Growth related, i.e. severs'. Walter and Ng (Walter & Ng, 2002) have previously demonstrated youth football players were in a dorsiflexed foot position or 'negative heel position' in cleated footwear during running. A 'negative heel position' increases the pressure on the growth centre of the calcaneus which can in turn increases the pull on the Achilles tendon and plantar fascia potentially leading to Severs' disease (Walter & Ng, 2002). Staff reported a lack of padding at the back players' football boots and overall poor fit which could potentially increase the incidence of Sever's disease amongst growing male players. Subsequently, this led to some medical staff altering players' football boots by adding heel raises, padding, cushioning, or cutting holes in the material to alleviate pressure and mitigate the risk of injury, 'Heel raise inserts added (particularly for severs)' and 'More padding at the back of the boot'. Further research is certainly required in this area to ascertain whether the addition of a heel raise into players football boots can reduce the incidence of calcaneal apophysitis in youth soccer players. This is currently common practice in Australia and New Zealand with the use of an Asics football boot that incorporates a 10 mm heel lift, however, no research has been carried out to date on its effect.

Concerns about safety during pitch side injury management
Another interesting point was medical safety surrounding laceless boots. Staff reported foot assessment during pitch side injury management required boots to be cut off, e.g. 'Difficulty taking on/off in medical scenario, at times, requiring to be cut off (especially Nike hyper venom-type sock boots)'. This poses a list of critical issues: delaying medical treatment, adding additional stress on medical staff, and cost of replacement. This is certainly an area for brand manufacturers to focus on so as not to hinder player safety through their boot selection.

Importance of education on boots-staff, players, parents
Assessing medical staff provided the authors of this study with a novel insight into their perception of player's football boots and football boot choice. Medical staff reported players … selected their boots for aesthetic reasons over function, e.g. 'Much of the time the players are choosing boots that look good (particularly lace-less boots) and these choices are usually at the detriment of their foot support/functional allowance', let sponsorship dictate their football boot selection, e.g. 'With the majority of players, they get sent the latest boots to wear every 6 weeks, with no individuality. Only Table 3. Modifications and amendments performed on academy football boots.
Insole/plantar foot 20 "Orthotics" "Insoles" "Insoles adaptation" "Insoles fitted (low arch/flat feet support)" "Insoles" "Podiatry and medicks staff [ … ] if a player requires further medial arch support to help reduce pronation." "Insoles" "Customised insoles" "Moulded insoles" "Adapted [ … ] insoles" "Custom orthotics" "removeable orthoses" "Foam padding to [ … ] arch" "Areas of the insole removed, or additions made to this to impact biomechanics" "Only insole manipulation" "Moulded insoles" "Orthotics made by podiatrists" "Insoles. Arch support. Great toe offload" "Custom insoles and make-shift padding by myself" "Insoles" Outsole 10 "Player changed some mouldies into stud because more comfortable" "Adapted [ … g studs" "Stud removal" "Boot shape moulded" "Carbon fibre in soul plate, building up around heel cup, changing footplate of boot to a different model" "Stud configuration changed in attempt to offload 5th metatarsal" "Changing moulds for studs" "Studs added to hard ground shoes by manufacturer" "Increase sole rigidity" "Various different studs can be fitted and adapted to the playing surface." "The addition of a carbon fibre support to the 5th metatarsal area for one player." Heel Padding 6 "Additional heel padding" "More padding at the back of the boot" "Podiatry and medicks staff if boots have poor heel padding" "Foam padding to heels" "Donuts on heels" "Heel cups" Inserts 4 "Heel raise inserts added (particularly for severs)" "Heel raise for severs" "Built in heel raises" "Heel insert" Unspecific Cut outs 7 "Cut holes to decompress boney spurs" "Padding in areas of bony prominences" "Cutting the boot in places to make more comfortable" "Cutting areas" "Cutting areas" "Part of boot cut away" "Cut out" Taping 1 "Additional taping for support" Padding 2 "Addition of padding." "Shoes had padding inserted in areas required post-surgery by manufacturer" Other 1 "Everything and anything" Upper 3 "Stretching to increase size / width." "Areas of the upper cut out" "Shoes made wider by manufacturer" Sock lining 1 "In modern style boots with a sock like fit that extend up ankle, I have also seen a player cut this off to relieve pressure in the area because it was uncomfortably tight, even though the rest of the boot was a perfect fit for his foot" N ¼ 33.
the top players who can afford to be more vocal would ask about changing their boots. So we see frequent variation in boot type, design, etc.' chose the wrong stud for the given surface and weather conditions, e.g. 'Player's not wearing the correct boots for certain weather conditions'. frequent changing of football boots to be problematic, 'Insufficient consideration from the player for a period to break the boots in and frequent switching of boots'.
Many responses from medical staff on the problems encountered indicate a perceived lack of education from a player or parent's perspective. Educating both on football boot selection could potentially reduce the risk of injury and the medical staff workload as well as potentially increase player's comfort and performance. This is particularly important when football boot sponsorships are introduced as outlined in this response; 'Players need brand/sponsor responsibility to educate players on what a well fitted, supported boot should feel like. They should let players know they have a choice to modify if required and representatives should be more visible for this reason'. Responsibility for delivering this education is debatable. Medical staff may not possess the knowledge to educate players whilst manufacturers may possess a certain bias towards own products and marketing strategies. However, online information is available regarding footwear measurements for children and may be of value to medical staff dealing with this age cohort (Price et al., 2021).
Research is also limited on male academy players in comparison to their senior counterparts. However, the literature in a non-sporting context has shown young people to select footwear based on aesthetics rather than function which was also highlighted by medical staff in the survey (Price et al., 2021). This again, can be to the detriment of the player not selecting a boot that is most suited to their foot type/injury pattern. Boot modification 3 "Softening strategies, [ … ] the odd re-building of an orthotic (Medial arch support/heel raise/1MTPJ offload)" "Orthotics" "Modification" Injury risk/management 4 "Blister patches/2nd skins" "Questions re injury risk" "Only when there's a problem such as sore heels or toes and usually seeking a solution to offload pressure areas" "I get asked about [ … ] and which boots provide good support to prevent injuries." Fit/size 3 "Which are best for their foot shape and style." "Size recommendations" "General -shape, style" Support 3 "How to get best support" "What boots help with [ … ] balance" "I get asked about football boot support " Surface fit 2 "Boot selection for differing surfaces" "What surface they should be used for." Aesthetics 1 "Asking opinions of ones they have around how they look" Performance 1 "What boots help with speed" General 1 "Only really players with previously identified issues." N ¼ 11. Table 5. Elaboration on satisfied with the current football boot market for academy players.

Topic Number of responders Example quote
Aesthetics focus 5 "I feel the market focus more on aesthetic rather than comfort" "It's mainly fashion based." "Need to be more informed choices based on boot quality not fashion" "Football boots appear to be more worried in how the look and feel to a player than any consequences they may have over safety and protection" "Focus on style rather than function" Lack of growth focus 2 "Boots need to consider foot posture and rapid growth/ changes of foot" "There's no consideration for growth" Material 2 "I find them material too light" "Material used does not provide adequate protection" Lack of performance focus 1 "There's no consideration [ … ] performance" Education of players/parents 3 "Kids and parents don't have the understanding how important are the right boots for training/playing" "Players need brand / sponsor responsibility to educate players on what a well fitted, supported boot should feel like. They should let players know they have a choice to modify if required and representatives should be more visible for this reason." "There does not seem to be any legislation, it is just a free for all to purchase what your favourite player wears" Costs 1 "Boots are too expensive" Mass focus 1 "Better supporting and better comfort of boots. Has been sacrificed for reduced weight in many boots" Customisability 1 "I believe boots should be custom fit to the individual." N ¼ 14.
As one of the few external modifiable injury, comfort, and performance factors to a players' game (Thomson et al., 2019), the importance of possessing the evidence to support education of youth players on what football boots to wear given their foot shape, the playing surface, and the weather on a given day is pertinent to their development and reducing the risk of injury which can impact their progression into professional adult football. A solution could be the introduction of tailored footwear education and assessment programmes by a qualified expert.

Strength and limitation
An obvious strength of this study is it is the first to assess medical staff's perception of football boot fit in an elite academy set up whereby the problems they encounter, the modifications made, and advice sought from players was reported. A population-based limitation of this study is its bias towards medical staffs' views. Those perceptions of players, parents, or other members of staff working in academy football may have different opinions or views regarding football boots.
It should also be acknowledged that within the academy issues are likely to vary with age groups. As most academic staff cover many or all age groups in an academy, no distinction was made for responses based on age groups. Future research could strengthen the understanding of agespecific football boot issues.

Conclusion
Medical staff found players to choose their boots based on aesthetic reasons over fit and comfort. As a result of selecting boots based on their appearance, staff found players having to 'break in' new boots. A relationship between medical condition, such as stress fractures, Severs' disease, blisters, and abrasions forces staff to modify players' football boots. Frequent changing of boots and the tight-fitting nature of youth players' football boots to cause the most reported problems. Education of players was also desired. The findings of this study highlight the benefit a tailored footwear education and assessment programmes by a qualified expert.
The study also highlighted key concerns not currently supported by research. Future research should aim to gather further quantitative assessment on how football boot designs can minimize injury risks, whilst optimizing comfort and performance in academy players.

Disclosure statement
AT and KK have previously received funding from football boot companies for research purposes.

Funding
None to declare.