https://orcid.org/0000-0002-8379-3530
Figures
Abstract
Background
Physical and psychological stress can precipitate Acute Coronary Syndrome (ACS) events. Football (soccer) is a popular sport globally, with referees covering significant distances, often at high-intensity during a match, and facing potentially intense psychological stress from high-stakes decision-making and potential verbal abuse from players and spectators. The aim of this scoping review was to identify what is known about the cardiovascular health and risk of acute cardiac events in referees during football matches.
Methods
A librarian-assisted search of six databases was completed, with publications written in English or with English translation available included. The PRISMA checklist was utilised and data were extracted from publications to form both descriptive and thematic analyses.
Results
Analysis of the publications identified five key themes: 1) the cardiovascular risk factors profile of football referees (prevalence of hypertension, dyslipidaemia and diabetes), 2) psychological stress and abuse experienced by referees (both verbal and physical abuse are reported at all levels of football, contributing to stress, anxiety, and anger), 3) physical intensity and activity levels of football referees (distance covered per match), 4) physiological aspects of football refereeing and 5) cardiac events on the football field (referees are rarely involved in providing CPR).
Conclusions
Evidence indicates that football referees face significant cardiovascular demands and psychological stress, along with a vulnerability to physical abuse, yet there is a lack of research on educational interventions to promote their cardiovascular health. Additionally, referees may act as first responders during ACS events, highlighting the necessity for them to be knowledgeable about relevant symptoms and trained for effective response.
Citation: Plasto TM, Tofler GH, Buckley T (2026) Football (Soccer) refereeing and cardiovascular health: A scoping review. PLoS One 21(4): e0346360. https://doi.org/10.1371/journal.pone.0346360
Editor: Julio Alejandro Henriques Castro da Costa, Portugal Football School, Portuguese Football Federation, PORTUGAL
Received: October 24, 2025; Accepted: March 18, 2026; Published: April 2, 2026
Copyright: © 2026 Plasto et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Aerobic exercise is typically thought of as beneficial for cardiovascular health, muscle strength and mental health [1]. However, a paradox exists where an increase in myocardial infarction (MI) and sudden cardiac death is seen occasionally in those exercising or who have recently completed exercise [2]. While these events are rare, particularly during football (soccer) matches, they are often widely publicised, such as in the case of Christian Eriksen, a Danish professional football player who collapsed on the pitch during the EURO 2020 competition and was resuscitated on the field [3]. Several anecdotal reports in the print media highlight cardiac events in football referees too, including an international-level official requiring a coronary stent after suffering an MI at home following a training session [4], a Bolivian referee dying in 2019 after suffering an MI on the field [5] and a referee’s life being saved in an American College football match with the aid of a defibrillator [6].
Football referees not only require sufficient level of cardiorespiratory fitness but are required to be mentally focussed for the duration of the match, where split second decisions can impact on the outcome. This decision making can be further complicated by the fact that players may exaggerate their response to draw support from the referee. Additionally, amateur football can be seen by some players to be a stress outlet, potentially releasing pent-up emotions from work and family life [7]. All of these factors make refereeing a football match potentially a complex, stressful and challenging task. Since emotional stressors and strenuous exertion are known to precipitate Acute Coronary Syndromes (ACS) [8–10], these factors combined suggest that football referees are potentially at increased risk of experiencing ACS events themselves during a game and may also be required as first responders for other participants of a football match.
A scoping review was conducted to summarise and map the available peer-reviewed literature related to cardiovascular risk factors, and risk of ACS in football referees. The findings inform a program of research investigating ways to potentially support referee cardiovascular health.
Methods
Search strategy
The scoping review was guided by the recommended methodology of Arksey and O’Malley [11] and expanded on by Levac and colleagues [12]. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRIMSA) and its extension for Scoping Reviews (PRISMA-ScR) checklist was used (S1 Fig). No ethical approval was required for this review.
- Stage 1: Identify the research question/s
Research questions were formulated: “What is known about cardiovascular risk factors in football referees?” and “What data or evidence exists regarding cardiovascular events in football referees?”.
- Stage 2: Identifying relevant studies
Studies were included if they met the following inclusion criteria:
- Referees that officiate football games of any age group, sex or geographical location
- Published in English in peer-reviewed journal or with English translations available
- Evaluated potential cardiovascular risk factors or cardiovascular events on the pitch in which referees were involved
Exclusion criteria:
- Opinion pieces/opinions, magazine articles, case reports, papers with no data
- Studies where the key focus was on decision-making of football referees and not the impact of decisions or cardiovascular risk factors
Search strategies and databases
A librarian-assisted systematic search of six databases was completed on 8 June 2024, including: CINAHL, Excerpta Medica database (EMBASE), MedLine, SCOPUS, SPORTDiscuss and Web of Science, utilising Boolean operators with keywords, with consultation with a university librarian (S2 Fig). A further search was completed on 21 July 2025, with one new publication identified.
- Stage 3: Study selection
Title and abstract screening were completed through the online application EndNote, with the software utilised to remove duplicates, with a manual review following this. Primary screening of titles and abstracts was completed by one reviewer (TMP), with discussion with a second reviewer (TB). Any disagreements were resolved with input from a third reviewer (GT). Full text articles were then retrieved utilising the EndNote software. Despite a thorough database search, including university librarian support, 21 full-text articles could not be found and were excluded from final analysis.
- Stage 4: Charting the data
For each article, key information was extracted into a matrix table as described by Pollock and colleagues [13]. Information included: author, year, location, journal, design, objective, methods and conclusion.
- Stage 5: Collating, summarising and reporting results
Articles were collated into a summarised matrix table (S1 Table) with key themes identified from the data, with inductive coding of themes as discussed by reviewers and further subcategorised based on any existing sub-themes, this was done in an iterative manner, with ongoing refinement until complete agreement between reviewers.
Results
Findings and patterns
In total, 105 research study publications were included for final review, (Fig 1). The countries of included studies is presented in Fig 2, with a majority (61.0%) utilising European referees, a further 14 utilising an international group of football referees, with the remaining studies originating from a variety of countries. Five publications were published prior to 2000, with a notable increase in publications since 2010 (Fig 3). Fifty-five studies focussed on national level or professional level football referees, 30 studies evaluated amateur football referees and 20 studies included both amateur and professional referees (Fig 4).
Key themes identified
Analysis of the publications identified five key themes in the research literature: 1) cardiovascular risk factors of football referees, 2) psychological stress experienced by referees, 3) physical activity of football referees, 4) physiological aspects of football refereeing and 5) cardiac events on the football field (Table 1).
Cardiovascular risk factors in football referees
The prevalence of cardiovascular risk factors in different football referee populations have been reported in five studies, reporting on risk factors such as hypertension, dyslipidaemia and tobacco smoking [14–18], all without control comparisons. In referees selected for the 2010 and 2014 FIFA World Cup, cardiovascular risk factors reported included dyslipidaemia (prevalence 2.2% (n = 2) in 2010 cohort vs 16.0% (n = 25) in 2014 cohort) and hypertension (prevalence 1.1% (n = 1) in the 2010 cohort vs 4,5% (n = 7) in 2014 cohort) [16,17].
One study compared referees with a non-referee population, reporting lower Body Mass Index (BMI), less truncal and visceral adipose tissue, significantly lower levels of hypertension and fewer tobacco smokers in the referee group, although this study was not age-matched [19]. In addition, three studies reported that elite level football referees had similar heart structure to football players when assessed by echocardiography with regard to left ventricular (LV) mass, LV wall thickness and LV cavity dimension [20–22].
Stress Testing in football referees
Studies of electrocardiogram (ECG) testing in football referees from all levels, including World Cup referees, indicate a low prevalence of pathological changes, with occasional instances of ST segment depression and T-wave inversion, which did not correlate with significant cardiovascular disease on follow up [15,17,18]. Overall, these results indicate that while some referees may demonstrate non-specific ECG findings, the majority demonstrate normal cardiac function.
Psychological stress reported by football referees
Psychological stress is a commonly experienced emotion among football referees, particularly due to fear of making a mistake [23–26], lack of formal recognition for their efforts [26,27] and fear of physical or verbal abuse [23–30]. Stress from factors external to football, such as family support, travel for matches and non-referee occupational stress also impact the emotionality and functionality of referees [7,31–34]. Three studies have also reported similar levels of perceived stress during a match between the referee and their assistant referees [35–37].
More experienced football referees generally experience a greater prevalence of positive psychological emotions and fewer negative [38–47]. However, a study involving elite Danish officials found that they experience higher anxiety levels than those refereeing games at a lower levels [48]. Additionally, referees <38 years of age exhibited greater anxiety, depression, burnout and stress than their older counterparts [41,42,49,50]. Notable one study revealed that negative emotions often surface at the start of a match, with initial feelings of happiness and excitement giving way to anxiety at kick-off [51]. Furthermore, single season studies of professional referees in Europe documented an increase in anxiety, depression, sleep disturbance and eating disorders alongside a decrease in self-confidence by the end of the season compared with pre-season testing [52,53]. Mental health conditions such as anxiety/depression (up to 43% prevalence), eating disorders and alcohol misuse (20% prevalence) [52] have been reported in European football referees [54], with increased prevalence compared with the general population.
Psychological burnout has been reported at all levels of refereeing [41], including in Spanish (prevalence 2.4%) [55] and Turkish professional referees (mean score 24.5 on Pines and Aronson’s (1988) burnout scale, indicating low-moderate levels of burnout) [56]. Female referees have been noted to have higher prevalence of burnout than their male colleagues [57–59] and centre field referees reported higher incidence of burnout than assistant referees [56,60].
Abuse faced by football referees
In Spain, football accounts for 93–98% of violent incidents in sports, with referees being the targets in 40–50% of these occurrences, as indicated by a review from the Spanish Department of Sport [61]. Notably, the total number of reported incidents decreased by nearly 50% over the decade from 2006 to 2016; however, the authors did not provide an explanation for this decline.
A study of 4,367 French and Dutch officials found that 68.1% of French and 51% of Dutch referees had experienced some form of verbal abuse, while physical abuse was reported in 17% of the French cohort and 15% of the Dutch cohort [62]. These participants were recruited via emails from their national refereeing department and abuse was assessed via self-reported questionnaires. The findings on physical abuse are consistent with a study which reported that 15% of surveyed Swedish referees had been physically abused in their role [58]. Additionally, it was noted that 22% of surveyed French referees and 12% of Dutch referees were considering quitting refereeing in the next 12 months due to the abuse experienced [63].
Abuse is a key reason why football referees cease officiating, with former English referees from all levels of the game identifying the main reason for leaving refereeing as due to the emotional stressors and abuse faced from other participants in the sport [64], which is reinforced in a study of Canadian officials [65]. Campaigns to ameliorate the stressors faced by football referees have struggled to gain traction or have meaningful outcomes [66–68].
Physical activity of football referees
Professional football referees cover a substantial distance during matches, averaging between 9–14 km, while non-elite officials cover 6.7 to 11 km; female referees average around 10 km [69–88]. Assistant referees typically cover 5.8 to 6.8 km, engaging in more walking and a higher frequency of sprints compared to centre referees [73,80]. Elite referees cover more distance than amateur ones [89], with a significant portion (>45%) of their movement occurring at speeds exceeding 13.1 km/hr [70,71,80,84,90]. Referees utilize various movement patterns, including running, walking, and moving backwards to optimize their positioning [81,90,91], while assistant referees may cover up to 30% of their distance side-stepping [88]. Research on distance covered in each half is mixed, with some studies showing no significant differences between halves [73,90,92,93], while others indicate a decrease in overall distance or medium-intensity activity during the second half [78,86,94–97].
Cardiovascular intensity whilst refereeing a football match
Both amateur and elite football referees operate at a high level of cardiovascular intensity for significant periods of a match [98], based on maximum HR (HRmax) calculations, often spending >80% of a match at >85% of estimated HRmax [99–102]. This has been reported in referees from many countries including Spain [103], England [86], Italy [69,92,96,104,105], Brazil [1,106], Australia [81], South Africa [107], Denmark [79], Iran [108] and in European international-level referees [109–111]. In addition to heart rate, lactate levels were noted to be elevated in match officials post-match compared with pre-match [112,113]. Assistant referees appear to spend less time during a match at high levels of cardiovascular intensity compared to central referees, with only 20% of match time spent with HRmax > 85%, with longer periods of standing [114–116].
There are fewer studies focussed on female referees, however it appears from studies that they have a similar cardiovascular response during a match to male referees [99] but fewer sprints per match [88,117,118].
Cardiac events on the football field
An analysis of a five-year period of the International Federation of Association Football (FIFA) sudden death registry (FIFA-SDR) from 2014–2018 identified that there were 617 cases of reported sudden deaths in players, with 95% occurring at the amateur level [119]. 76% of cases reported information about cardiopulmonary resuscitation (CPR) efforts, with prompt initiation in 68% of cases and a noted increase in survival when initiated by a CPR-trained person, with referees listed as participating in the CPR efforts in ~5% of player cases [119]. No studies were identified in the literature reporting the incidence of cardiac events in referees during or after football games.
CPR competency in Basic Life Support (BLS) and Automatic External Defibrillator (AED) use in football referees was reported in one study [120]. In this study of a cohort of amateur referees, one-third of the sample knew what an AED was but only 8% knew how to use it. Following a brief education intervention that included CPR practice, all participants achieved 70% or higher CPR quality scores and were determined to be able to use the AED properly (54.2% without any incidents) [120].
Discussion
A total of 105 studies were identified that focussed on cardiovascular events during matches, potential cardiovascular risk factors, physical activity and psychological stress associated with football refereeing. A majority of studies were case reports (n = 31), with qualitative (n = 30) and cross-sectional (n = 11) studies making up the other large portion. This area of research has begun to expand with 83 peer-reviewed publications since 2010, with the largest population of studied referees being from Spain (n = 24). Importantly given that football is known as “The World Game” this review identified that refereeing cohorts from across the world have been studied providing a breadth of populations for analysis. A majority of publications were case reports and/or observational studies.
This review identified five main themes regarding football referees, cardiovascular risk factors and exposure to potential ACS events which were: 1) cardiovascular risk factors, 2) psychological stress experienced, 3) physical activity, 4) physiological aspects of football refereeing and 5) cardiac events on the football field.
Football referee responses to potential cardiac events
This review identified that football referees were involved in CPR when required during a match in ~5% of cases [119], although data were available in only one publication. In one study, referees knowledge was limited on CPR, however with a short education session, they were able to attain competency in CPR [120]. The FIFA-SDR database indicated prompt CPR as being beneficial to the outcomes of players who suffered from ACS events, with referees often close to players on the field due to the nature of their role [119]. According to the Laws of The Game, every formally sanctioned match should be officiated by at least one registered referee [121], providing an avenue for improvement with respect to upskilling football referees at all levels regarding BLS and CPR. This is particularly important at the amateur level, where it is unlikely there will be a team physiotherapist, medical professional or paramedic crew at the match, as is often the case at professional and semi-professional level matches.
Although media reports exist of cardiac events in football referees [4–6], the review highlighted no peer reviewed publications or central repository of information related to referees. This is a significant area for improvement at the international level in order to accurately profile the number of ACS events and sudden deaths noted in football referees.
Cardiovascular risk factors in football referees
Referees selected for the 2010 and 2014 FIFA World Cup demonstrated prevalence of cardiovascular risk factors including dyslipidaemia and hypertension [16,17], however no studies exist comparing referees with an age-matched population. While cardiovascular risk factors have been investigated in cohorts of elite match officials (n = 4), especially focussing on biochemical-related risks, fewer (n = 2) studies focus on the amateur referee cohort, who are larger in size and likely to have higher risk factors when compared with their elite referee colleagues, who have been reported to have similar fitness to elite players.
Understanding the risk factors present in football referees is a crucial step towards tailoring both education and screening programs towards these match officials in order to ideally prevent episodes of sudden cardiac death or ACS while officiating a match. FIFA have introduced a mandatory yearly pre-screening for all professional players [119], though it is unclear how this is expanding to include professional referees and whether this is being adopted at the amateur level of football refereeing.
Psychological stress faced by football referees
This review has demonstrated that both verbal and physical abuse are prevalent in football and directed towards football referees at all levels of the game. This review highlighted that the abuse received by referees is a significant reason towards them leaving the refereeing ranks. Abuse received while refereeing a match contributes to the acute psychological stress faced by football referees and as a known ACS risk factor [10,122], may increase risk of ACS events in match officials. While studies investigating emotional stressors have been highlighted above, no link has been established between this stress and documented ACS events in football referees.
Physiological aspects to refereeing
Football referees undertake a significant cardiorespiratory load when they referee a match, covering between 9–14 km in a 90-minute period [63–74], spending a significant portion of each match at a HR > 85% of their estimated maximum HR. This has been most closely examined in the professional football referee cohort, with emerging evidence in the amateur cohort of referees. The paradox of exercise describes that cardiorespiratory effort is beneficial for long term health, but a transient increased risk of ACS events exists with acute or prolonged physical exercise [2,9]. As such, football referees may be at an increased risk of a triggered ACS events during or immediately after a match from this dual risk factor exposure. especially if chronic risk factors are also present.
Limitations of the studies identified
Limitations of the review.
Studies were included in this review if they were published in English or translated to English only. Given the international nature of football, we may have excluded relevant non-English articles. There are a limited number of prospective studies identified in this review and therefore causal inference and generalisability may be limited.
Limitations of data.
Many of the studies reviewed were studies of professional or semi-professional football referees. While they provide useful information regarding the cardiorespiratory profile of a football referee, these officials are more likely to have dedicated time to train and receive advice from trainers, dietitians and physiotherapists etc. In contrast, amateur referees often play football and referee on the same day, or referee multiple matches in a day or across a weekend. This has the potential to impact their fitness and ability to respond appropriately in a match, while also increasing fatigue and stress on their cardiorespiratory system. There are no published studies that discuss this theme in great detail and is something that has the opportunity to be further investigated.
Secondly, a majority of the reviewed studies were of male football referees. This potentially skews the data towards this cohort of officials, though based on Australian (87%) [123] and English (92%) [124] data, a majority of referees are male. Thirdly, while cardiovascular risk factor profiles have been reported in several referee cohorts, only one study compared these with a non-referee cohort. This somewhat limits the ability to interpret this data with reference to whether football referees have increased or decreased risk compared with the broader population.
Conclusion
The growing body of evidence highlights the cardiovascular demands, risk factors, and psychological stressors faced by football referees, although with limited data on the occurrence of cardiovascular events. Findings indicate that referees experience considerable cardiorespiratory strain during matches while also being exposed to significant psychological stress and physical abuse. Despite this, there is a notable lack of research on educational interventions aimed at promoting cardiovascular health among referees. Furthermore, referees may serve as first responders during ACS events on the field, highlighting the need for them to be well-informed about the symptoms to monitor in themselves and others, as well as to receive appropriate training for effective response.
Supporting information
S1 Fig. Preferred Reporting Items for Systematic reviews and Meta- analyses extension for Scoping reviews (PRISMA-ScR) checklist.
https://doi.org/10.1371/journal.pone.0346360.s001
(PDF)
S2 Fig. Example search strategy (utilised in MedLine).
https://doi.org/10.1371/journal.pone.0346360.s002
(PDF)
Acknowledgments
The authors would like to acknowledge Kanchana Ekanayake at the University of Sydney library for her help and support. All authors provide their consent to publication of the data. No patient consent is required.
References
- 1. Costa EC, Vieira CMA, Moreira A, Ugrinowitsch C, Castagna C, Aoki MS. Monitoring external and internal loads of brazilian soccer referees during official matches. J Sports Sci Med. 2013;12(3):559–64. pmid:24149165
- 2. Maron BJ. The Paradox of Exercise. N Engl J Med. 2000;343(19):1409–11.
- 3. Karen M. In scary scene at Euro 2020, Eriksen collapses on the field. Associated Press. 2021.
- 4.
Davis D. UEFA referee Ovidiu Hategan ‘suffers a heart attack’ days after being fourth official in Wales win. Daily Mail Online. https://www.dailymail.co.uk/sport/sportsnews/article-10659249/UEFA-referee-Ovidiu-Hategan-suffers-heart-attack-days-fourth-official-Wales-win.html. Accessed 2023 October 17.
- 5.
Press A. Football referee Victor Hugo Hurtado suffers heart attack and dies, Always Ready vs Oriente Petroler. https://www.news.com.au/sport/football/bolivian-football-in-mourning-after-a-referee-collapsed-and-later-died/news-story/adf94c33390378005411826bbacd41e5. 2019. Accessed 2023.
- 6.
McCarthy C. Hanover athletic trainer saves referee’s life after heart attack. Boston 25 News. https://www.boston25news.com/news/local/hanover-athletic-trainer-saves-referees-life-after-heart-attack-soccer-field/QXDOPGBZAFEDHE5G4JF4TRSEC4/. 2020. Accessed 2023 August 21.
- 7. Voight M. Sources of stress and coping strategies of US soccer officials. Stress and Health. 2008;25(1):91–101.
- 8. Buckley T, Hoo SYS, Fethney J, Shaw E, Hanson PS, Tofler GH. Triggering of acute coronary occlusion by episodes of anger. Eur Heart J Acute Cardiovasc Care. 2015;4(6):493–8. pmid:25713468
- 9. Buckley T, Soo Hoo SY, Shaw E, Hansen PS, Fethney J, Tofler GH. Triggering of Acute Coronary Occlusion by Episodes of Vigorous Physical Exertion. Heart Lung Circ. 2019;28(12):1773–9. pmid:30555009
- 10. Chan B, Buckley T, Tofler GH. Emotional Stress and Physical Exertion as Triggers of Acute Myocardial Infarction. Am J Cardiol. 2023;203:285–7. pmid:37517121
- 11. Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32.
- 12. Levac D, Colquhoun H, O’Brien KK. Scoping studies: advancing the methodology. Implement Sci. 2010;5:69. pmid:20854677
- 13. Pollock D, Davies EL, Peters MDJ, Tricco AC, Alexander L, McInerney P, et al. Undertaking a scoping review: A practical guide for nursing and midwifery students, clinicians, researchers, and academics. J Adv Nurs. 2021;77(4):2102–13. pmid:33543511
- 14. Maskhulia L, Akhalkatsi V, Chelidze K, Kakhabrishvili Z, Matiashvili M, Chabashvili N. Pre-participation cardiovascular screening of football referees: clinical findings and experience. Eur J Prev Cardiol. 2015;1:S43.
- 15. Urhausen A, Vivas JP, Lambert C, Weiler B. Cardiovascular stress in football referees. Ger J Sport Med. 2022;73(1):30–4.
- 16. Niederseer D, Franz AC, Keller D, Junge A, Bizzini M, Dvorak J. Cardiovascular screening of football referees for the 2014 FIFA Football World Cup in Brazil - time for revision of current screening concepts in competitive master athletes?. Eur J Prev Cardiol. 2017;24(Supplement 1):S48.
- 17. Bizzini M, Schmied C, Junge A, Dvorak J. Precompetition medical assessment of referees and assistant referees selected for the 2010 FIFA World Cup. Br J Sports Med. 2012;46(5):374–6. pmid:22144004
- 18. Ferreira M, Ferreira C, Carlos de Abreu L. Risk of cardiovascular disease in soccer referees: a cross sectional study. jhgd. 2022;32(3):298–308.
- 19. Wesołowska J, Jurczak A, Wieder-Huszla S, Jarosz K, Jurewicz A, Marchlewicz M. Comparison of the risk of cardiovascular diseases, stroke, and diabetes among the selected group of football referees and the group of general population men from Northern Poland - a pilot study. Eur Rev Med Pharmacol Sci. 2022;26(9):3151–60. pmid:35587065
- 20. Galanti G, Pizzi A, Lucarelli M, Stefani L, Gianassi M, Di Tante V, et al. The cardiovascular profile of soccer referees: an echocardiographic study. Cardiovasc Ultrasound. 2008;6:8. pmid:18269755
- 21. Ruiz Caballero JA, Brito Ojeda E, García-Aranda JM, Mallo J, Helsen W, Sarmiento S, et al. Echocardiographic study of structure and functional cardiac profile of football referees. J Sports Med Phys Fitness. 2011;51(4):633–8. pmid:22212266
- 22. Gianturco L, Bodini B, Gianturco V, Lippo G, Solbiati A, Turiel M. Left ventricular longitudinal strain in soccer referees. Oncotarget. 2017;8(24):39766–73. pmid:28199991
- 23. Blumenstein B, Orbach I. Development of Psychological Preparation Program for Football Referees: Pilot Study. Sport Science Review. 2014;23(3–4):113–25.
- 24. de Moura Simim MA, Melo Ferreira R, Campos Souza MV, Custódio Marques A, Correa da Silva BV. Psychological and social factors are subjective stress source in football referees. Rev Bras Futsal Futeb. 2018;10:475–80.
- 25. Gillué GS, Laloux YR, Álvarez MT, Cruz IF, Feliu J. Sources of stress inside and outside the match in football referees. Apunts Educ Fis Deportes. 2018;2018(132):22–31.
- 26. Neil R, Bayston P, Hanton S, Wilson K. The influence of stress and emotions on association football referees’ decision-making. bpssepr. 2013;9(2):22–41.
- 27. Louvet B, Campo M. Do high emotional intelligent soccer referees better cope with competitive stressors?. Mov Sport Sci/Sci Mot. 2019;(105):17–26.
- 28. Hemmings B, Graydon J. Sources of stress and the incidence of burnout in national list and junior league status football referees in the 1992-93 season. J Sport Sci. 1994;12(2):195.
- 29. Gorczynski P, Thelwell R. Examining mental health literacy, depressive symptoms, help seeking behaviors, and wellbeing in soccer match officials in the UK. Int J Sport Psychol. 2022;53(1):25–35.
- 30. Aguirre-Loaiza H, Holguin J, Arenas J, Nunez C, Barbosa-Granados S, García-Mas A. Psychological characteristics of sports performance: analysis of professional and semiprofessional football referees. Psychol Sport Exerc. 2020;20(4):1861–8.
- 31. Can Y, ÇOban Ü, Soyer F. Understanding the effects of negative emotionality on stress of referees working in Turkey. J Phys Ed Sport Sci. 2011;5(2):165–74.
- 32. Liu Z, Zhao L, Wang S, Gao Y, Zhang L. The Association between Occupational Stress and Mental Health among Chinese Soccer Referees in the Early Stage of Reopening Soccer Matches during the COVID-19 Pandemic Outbreak: A Moderated Mediation Model. Int J Environ Res Public Health. 2022;19(24):16750. pmid:36554631
- 33. Parsons T, Bairner A. You want the buzz of having done well in a game that wasn’t easy: a sociological examination of the job commitment of English football referees. Movement & Sport Sciences. 2015;n° 87(1):41.
- 34. Martín-Sánchez ML, Marín-Farrona M, Gallardo L, García-Unanue J, Matute-Llorente Á, Casajús JA. Level of studies and experience of female football referees and assistant referees in Spain: Women’s First Division. Culture Sci Sport. 2021;16(50):653–60.
- 35. Gencay S. Magnitude of psychological stress reported by soccer referees. Soc Behav Pers. 2009;37(7):865–8.
- 36. Bambaeichi E, Movahedi AR, Abedini M. The relationship between cardiovascular risk factors and trait anxiety of Iranian referees and assistant referees in Premier League Soccer. Br J Sports Med. 2010;44(Suppl 1):i22.1-i22.
- 37. Slack LA, Butt J, Maynard IW, Olusoga P. Understanding mental toughness in elite football officiating: Perceptions of English Premier League referees. bpssepr. 2014;10(1):4–24.
- 38. Arjona CM, Fernandes BR, Dos Santos TD, Onetti WO, Rodriguez AC. Effect of the soccer referee’s experience in sports competition. Culture Sci Sport. 2022;17(51):41–51.
- 39. Castillo-Rodriguez A, Munoz-Arjona C, Onetti-Onetti W. National vs. Non-National Soccer Referee: Physiological, Physical, and Psychological Characteristics. Res Q Exerc Sport. 2022;93(4):804–12.
- 40. Cipriano P, Martins P, Duarte R, Preto L, Peixoto C, Moreira M. Investigation on Soccer Referees: A Narrative Review. Pol J Sport Tourism. 2019;26(3):20–8.
- 41. Da Gama DRN, Nunes RAM, Guimarães GL, E Silva LL, De Castro JBP, Vale RGS. Analysis of the burnout levels of soccer referees working at amateur and professional leagues of Rio de Janeiro, Brazil. J Phys Ed Sport. 2018;18:1168–74.
- 42. Lima Y, Devran S, Öz ND, Webb T, Bayraktar B. Examining the mental health status of referees in the turkish professional football league. Sci Med Footb. 2023;7(3):272–8. pmid:35621335
- 43. Slack LA, Maynard IW, Butt J, Olusoga P. An Evaluation of a Mental Toughness Education and Training Program for Early-Career English Football League Referees. The Sport Psychologist. 2015;29(3):237–57.
- 44. Hong E, Jeong Y, Downward P. Perceived organizational support, internal motivation, and work–family conflict among soccer referees. Managing Sport and Leisure. 2019;24(1–3):141–54.
- 45. López Aguilar J, Castillo-Rodriguez A, Chinchilla-Minguet JL, Onetti-Onetti W. Relationship between age, category and experience with the soccer referee’s self-efficacy. PeerJ. 2021;9:e11472. pmid:34178441
- 46. Fernandez XE, Priego-Ojeda M, Morente AR, Mora CA. Relationship between emotional intelligence, burnout and health perception in a sample of football Spanish referees. Retos. 2022;44:960–75.
- 47. Folkesson P, Nyberg C, Archer T, Norlander T. Soccer referees’ experience of threat and aggression: Effects of age, experience, and life orientation on outcome of coping strategy. Aggressive Behavior. 2002;28(4):317–27.
- 48. Johansen BT, Haugen T. Anxiety level and decision-making among Norwegian top-class soccer referees. International Journal of Sport and Exercise Psychology. 2013;11(2):215–26.
- 49. Soriano G, Ramis Y, Torregrosa M, Cruz J. Support against stress: how we can help referees?. Revista Kronos. 2017;16(1):1–10.
- 50. Orviz-Martínez N, Botey-Fullat M, Arce-García S. Analysis of Burnout and Psychosocial Factors in Grassroot Football Referees. Int J Environ Res Public Health. 2021;18(3):1111. pmid:33513797
- 51. Canedo Nogueira DF, Fontes L, Da Silva Gomes AR, Coelho Resende da Silva RM. Referees’ Emotions and Performance Perception: The Importance of Stress and Cognitive Appraisal. Cuad psicol deporte. 2022;22(2):156–70.
- 52. Gouttebarge V, Johnson U, Rochcongar P, Rosier P, Kerkhoffs G. Symptoms of common mental disorders among professional football referees: a one-season prospective study across Europe. Phys Sportsmed. 2017;45(1):11–6. pmid:27741403
- 53. Castillo-Rodriguez A, Lopez-Aguilar J, Alonso-Arbiol I. Relationship between physical-physiological and psychological responses in amateur soccer referees. Rev Psicol Deporte. 2021;30(3):73–85.
- 54. Kilic Ö, Johnson U, Kerkhoffs GMMJ, Rosier P, Gouttebarge V. Exposure to physical and psychosocial stressors in relation to symptoms of common mental disorders among European professional football referees: a prospective cohort study. BMJ Open Sport Exerc Med. 2018;4(1):e000306. pmid:29629180
- 55. Pedrosa I, Garcia-Cueto E. Burnout syndrome in elite referees: The Spanish professional soccer league (LFP) under analysis. Rev Iberoam Diagn Eval-Aval P. 2016;2(42):59–68.
- 56. Sirin Y, Dos Yilmaz E. Investigation of job satisfaction and burnout levels of Turkish Super League football referees. Nigde Uni J Phys Ed Sport Sci. 2017;11(1):87–96.
- 57. Pedrosa I, Garcia-Cueto E. Psychological aspects in elite referees: does the wage affect their emotional well-being?. Rev Psicol Deporte. 2015;24(2):241–8.
- 58. Devis-Devis J, Serrano-Dura J, Molina P. The Referee Plays to Be Insulted!: An Exploratory Qualitative Study on the Spanish Football Referees’ Experiences of Aggression, Violence, and Coping. Front Psychol. 2021;12:656437.
- 59. Marín-Montín J, Bianchi P. “Go and Wash up!”: Gender Violence in Female Refereeing and Its Media Coverage in Brazil and Spain. Communication & Sport. 2022;12(3):466–90.
- 60. De Oliveira AB, Penna EM, Pires DA. Burnout syndrome in soccer referees. J Sport Psych. 2017;27(4):31–6.
- 61. Fuente D, Cantón E, Montes F. Aggression towards referees in amateur football in Spain: A loglinear approach. Univ Psychol. 2019;18(3):1–13.
- 62. Webb T, Dicks M, Thelwell R, van der Kamp J, Rix-Lievre G. An analysis of soccer referee experiences in France and the Netherlands: Abuse, conflict, and level of support. Sport Management Review. 2020;23(1):52–65.
- 63. Dawson P, Webb T, Downward P. Abuse is not a zero-sum game! The case for zero tolerance of match official physical and verbal abuse. Eur J Sport Sci. 2022;22(3):417–24. pmid:33504289
- 64. Potrac PA, Hall ET, Nichol AJ. Fear, Anger, and Loneliness: Emotional Pain and Referee Attrition in English Grassroots Football. Sociology of Sport Journal. 2022;39(3):298–308.
- 65.
Taylor A, Daniel J, Leith L, Agnew J. An investigation of the psycho-social factors preceding dropout of Ontario soccer officials. Toronto: University of Toronto. School of Physical and Health Education; 1988.
- 66. Gardner P. Respect campaigns in football. World Soccer. 2008;49(2):16.
- 67. Webb T, Cleland J, O’Gorman J. The Distribution of Power through a Media Campaign: The Respect Program, Referees, and Abuse in Association Football. Journal of Global Sport Management. 2017;2(3):162–81.
- 68. Gorczynski P, Webb T. Developing a mental health research agenda for football referees. Soccer & Society. 2021;22(6):655–62.
- 69. Castagna C, Abt G, D’Ottavio S, Weston M. Age-related effects on fitness performance in elite-level soccer referees. J Strength Cond Res. 2005;19(4):785–90. pmid:16287368
- 70. D’Ottavio S, Castagna C. Physiological load imposed on elite soccer referees during actual match play. J Sports Med Phys Fitness. 2001;41(1):27–32. pmid:11405189
- 71. Dottavio S, Castagna C. Analysis of match activities in elite soccer referees during actual match play. J Strength Cond Res. 2001;15(2):167–71. pmid:11710400
- 72. Weston M, Castagna C, Impellizzeri FM, Bizzini M, Williams AM, Gregson W. Science and medicine applied to soccer refereeing: an update. Sport Med. 2012;42(7):615–31.
- 73. Barbero-Álvarez J, Boullosa DA, Nakamura FY, Andrín G, Castagna C. Physical and physiological demands of field and assistant soccer referees during America’s cup. J Strength Cond Res. 2012;26(5):1383–8. pmid:22395268
- 74. Mallo J, Navarro E, Aranda JMG, Helsen WF. Activity profile of top-class association football referees in relation to fitness-test performance and match standard. J Sports Sci. 2009;27(1):9–17. pmid:18979338
- 75. Joo CH, Jee H. Activity profiles of top-class players and referees and accuracy in foul decision-making during korean national league soccer games. J Strength Cond Res. 2019;33(9):2530–40. pmid:31008861
- 76. Martínez-Torremocha G, Martin-Sanchez ML, Garcia-Unanue J, Felipe JL, Moreno-Pérez V, Paredes-Hernández V, et al. Physical demands on professional Spanish football referees during matches. Sci Med Footb. 2023;7(2):139–45. pmid:35392769
- 77. Weston M, Castagna C, Impellizzeri FM, Rampinini E, Breivik S. Ageing and physical match performance in English Premier League soccer referees. J Sci Med Sport. 2010;13(1):96–100. pmid:18835743
- 78. Di Salvo V, Carmont MR, Maffulli N. Football officials activities during matches: a comparison of activity of referees and linesmen in European, Premiership and Championship matches. Muscles Ligaments Tendons J. 2012;1(3):106–11. pmid:23738256
- 79. Krustrup P, Bangsbo J. Physiological demands of top-class soccer refereeing in relation to physical capacity: effect of intense intermittent exercise training. J Sports Sci. 2001;19(11):881–91. pmid:11695510
- 80. Krustrup P, Helsen W, Randers MB, Christensen JF, MacDonald C, Rebelo AN, et al. Activity profile and physical demands of football referees and assistant referees in international games. J Sports Sci. 2009;27(11):1167–76. pmid:19705329
- 81. Johnston L, McNaughton L. The physiological requirements of Soccer refereeing. Aust J Sci Med Sport. 1994;26(3–4):67–72. pmid:8665280
- 82. Mazaheri R, Halabchi F, Barghi TS, Mansournia MA. Cardiorespiratory fitness and body composition of soccer referees; do these correlate with proper performance?. Asian J Sports Med. 2016;7(1):1–5.
- 83. Moreno-Perez V, Martín-Sánchez ML, Del Coso J, Felipe JL, Courel-Ibañez J, Sánchez-Sánchez J. Impact of COVID-19 lockdown on match activity and physical performance in professional football referees. Biol Sport. 2021;38(4):761–5. pmid:34937988
- 84. Castillo D, Cámara J, Castellano J, Yanci J. Football match officials do not attain maximal sprinting speed during matches. Kinesiology (Zagreb, Online). 2016;48(2):207–12.
- 85. Yanci-Irigoyen J. Changes in the physical fitness of soccer referees: a longitudinal study. RICYDE-Rev Int Cienc Deport. 2014;10(38):336–45.
- 86. Catterall C, Reilly T, Atkinson G, Coldwells A. Analysis of the work rates and heart rates of association football referees. Br J Sports Med. 1993;27(3):193–6. pmid:8242278
- 87. Choi Y, Roh J. Activity profile and physiological responses of Korean amateur football referees during matches. J Phys Ther Sci. 2018;30(2):351–4. pmid:29545712
- 88. Castagna C, Bizzini M, DʼOttavio S, Araújo Póvoas SC. Sex Differences in Aerobic Fitness in Top-Class Soccer Referees. J Strength Cond Res. 2018;32(11):3216–21. pmid:29140913
- 89. Rebolé M, Castillo D, Cámara JC, Yanci J. Relationship between the cardiovascular capacity and repeated sprints ability in high-standard soccer referees. Ibero-Am J Phys Act Sport Sci. 2016;5(3):49–64.
- 90. Adnan R, Muzayin N, Sulaiman N. Analysis of Movement Pattern among Referee in 2012 Malaysian Cup. JHSE. 2013;8(Proc3):S642–50.
- 91.
Bozdogan TK, Kizilet A, Bicer B, editors. The effect of morphological characteristics on the physical and physiological performance of Turkish soccer referees and assistant referees. Budapest, HUNGARY; 2017.
- 92. Castagna C, Abt G. Intermatch variation of match activity in elite Italian soccer referees. J Strength Cond Res. 2003;17(2):388–92. pmid:12741883
- 93. Rebelo-Gonçalves R, Pardal H, Coelho L, Antunes R, Amaro N. Physiological and mechanical loads in Portuguese sub-elite football refereeing - a preliminary study. Sport Psych Note. 2021;21(3):213–23.
- 94. Mallo J, García Aranda JM, Navarro E. Physical match performance of soccer referees and assistant referees in relation to the level of competition. J Sports Sci. 2009;26(133):335–44.
- 95. Fernández Vargas GE, Inácio da Silva A, Arruda M. Anthropometric profile and physical fitness of the professional referees Chilean soccer. Int J Morphol. 2008;26(4):897–904.
- 96. Castagna C, Abt G, D’Ottavio S. Activity profile of international-level soccer referees during competitive matches. J Strength Cond Res. 2004;18(3):486–90. pmid:15320668
- 97. Amatori S, Helsen WF, Baldari C, Serra T, Belli A, Guidetti L. High-speed efforts of elite association football referees in national and international matches. Journal of Sports Sciences. 2024;38(8):e417–22.
- 98. Santos-Silva PR, D’Andrea Greve JM, Pedrinelli A, Almeida AM, Osorio BB, Ferreira M. Comparing the Aerobic Fitness of Professional Male Soccer Players and Soccer Referees. Current Sport Medicine Reports. 2019;18(12):497–501.
- 99. Boullosa DA, Abreu L, Tuimil JL, Leicht AS. Impact of a soccer match on the cardiac autonomic control of referees. Eur J Appl Physiol. 2012;112(6):2233–42. pmid:21997680
- 100. Özdamar E, Hazir Aytar S, Kin Isler A. Investigation of the physiological load of football local referees during competition according to league level. J Phys Ed Sport Sci. 2021;19(1):29–38.
- 101. Müniroglu S. The relation between heart rate and running distances of football referees during the matches. Int J Appl Sports Sci. 2007;19(2):7–15.
- 102. Marchante A, Cervigon R. Assessment of physiological and psychological factors in nonprofessional football referees. Int J Psychophysiol. 2021;168(Supplement):S138.
- 103. Castillo Alvira D, Cámara Tobalina T, Yanci Irigoyen J. Influence of the maximum heart rate determination criterion on the quantification of the internal load in soccer refereeing. Arch Med Deporte. 2018;35(4):228–33.
- 104. Castagna C, Abt G, D’Ottavio S. Physiological aspects of soccer refereeing performance and training. Sports Med. 2007;37(7):625–46. pmid:17595157
- 105. Castagna C, Bizzini M, Araújo Póvoas SC, Schenk K, Büsser G, DʼOttavio S. Aerobic Fitness in Top-Class Soccer Referees. J Strength Cond Res. 2019;33(11):3098–104. pmid:29189582
- 106. Fernandes da Silva J, Teixeira AS, de Carvalho J, Do Nascimento Salvador P, Castagna C, Ventura AP, et al. Match activity profile and heart rate responses of top-level soccer referees during Brazilian national first and second division and regional championships. Sci Med Footb. 2023;7(3):263–71. pmid:35787742
- 107. Lategan L. Physiological profiles of South African soccer referees and assistant referees. Afr J Phys Health Educ Recreat Dance. 2011;17(4):675–93.
- 108. Halabchi F, Mazaheri R, Mansournia MA, Barghi TS. Study of selected health and performance related parameters among football referees of Iranian premier League. Pejouhandeh. 2012;17(4):1p-p.
- 109. Dolański B, Szwarc A, Heinig B, Sitek M. Physical activity profile of the referee and the assistant referee during official football matches. Balt J Health Phys Act. 2017;9(3):97–105.
- 110. Helsen W, Bultynck J-B. Physical and perceptual-cognitive demands of top-class refereeing in association football. J Sports Sci. 2004;22(2):179–89. pmid:14998096
- 111.
Ladelfa G, Centamore G, Platania G, Maccarione FP, Caliri L, Corsini M. Referees’ monitoring holter during official soccer matches. Turin: Edizioni Minerva Medica. 1994.
- 112. Castillo D, Yanci J, Cámara J, Weston M. The influence of soccer match play on physiological and physical performance measures in soccer referees and assistant referees. J Sports Sci. 2016;34(6):557–63. pmid:26523630
- 113. Senécal I, Howarth SJ, Wells GD, Raymond I, Mior S. The Impact of Moderate and High Intensity Cardiovascular Exertion on Sub-Elite Soccer Referee’s Cognitive Performance: A Lab-Based Study. J Sports Sci Med. 2021;20(4):618–25. pmid:35321134
- 114. Mallo J, Navarro E, Garcia Aranda JM, Helsen W. Physical demands of top-class soccer assistant refereeing during high-standard matches. Int J Sports Med. 2009;30(5):331–6. pmid:19301215
- 115. Ozaeta E, Fernández-Lasa U, Martínez-Aldama I, Cayero R, Castillo D. Match Physical and Physiological Response of Amateur Soccer Referees: A Comparison between Halves and Match Periods. Int J Environ Res Public Health. 2022;19(3):1306. pmid:35162329
- 116. Silva VL da, Depizzol CE do R, Carletti L, Vancini RL, Leopoldo APL, Leopoldo AS. State of health and physical fitness of cbf (brazilian soccer confederation) referees from the state of Espírito Santo. Rev Bras Med Esporte. 2019;25(2):147–51.
- 117. Martin-Sanchez ML, Oliva-Lozano JM, Garcia-Unanue J, Felipe JL, Moreno-Pérez V, Gallardo L, et al. Physical demands in Spanish male and female elite football referees during the competition: a prospective observational study. Sci Med Footb. 2022;6(5):566–71. pmid:36342831
- 118. Sánchez MLM, Oliva-Lozano JM, García-Unanue J, Krustrup P, Felipe JL, Moreno-Pérez V, et al. Association between Fitness Level and Physical Match Demands of Professional Female Football Referees. Int J Environ Res Public Health. 2022;19(17):10720. pmid:36078434
- 119. Egger F, Scharhag J, Kästner A, Dvořák J, Bohm P, Meyer T. FIFA Sudden Death Registry (FIFA-SDR): a prospective, observational study of sudden death in worldwide football from 2014 to 2018. Br J Sports Med. 2022;56(2):80–7. pmid:33361135
- 120. Jorge-Soto C, Fernandez-Mendez F, Gonzalez-Gonzalez Z, Fandino-Reissmann FG, Otero-Agra M, Barcala-Furelos R. Football referees as first responders in cardiac arrest. Assessment of a basic life support training program. Signa Vitae. 2018;14(2):41–5.
- 121.
Various. Laws of the Game 2024/25. Zurich, Switzerland: The International Football Association Board. 2024.
- 122. Zupancic ML. Acute psychological stress as a precipitant of acute coronary syndromes in patients with undiagnosed ischemic heart disease: a case report and literature review. Prim Care Companion J Clin Psychiatry. 2009;11(1):21–4. pmid:19333406
- 123.
Various. FA national participation report - 2024. Sydney, Australia: Football Australia. https://footballaustralia.com.au/sites/ffa/files/2025-02/21307_FA_Participation%20Reports_2024_High%20Res_FULL.pdf
- 124.
Various. FA publishes year one review of our refereeing strategy: to grow, guide and govern. https://www.thefa.com/news/2024/oct/24/refereeing-strategy-year-one-update-20242410#:~:text=Sam%20Allison%20is%20now%20a. 2024. Accessed 2024 October 24.