HHS Public Access

Author manuscript
Br J Sports Med. Author manuscript; available in PMC 2023 February 15.
Author Manuscript

Published in final edited form as:

Br J Sports Med. 2020 June ; 54(12): 711–718. doi:10.1136/bjsports-2018-099577.

Epidemiology of injuries in professional football: a systematic

review and meta-analysis
Alejandro López-Valenciano1,2, Iñaki Ruiz-Pérez1, Alberto Garcia-Gómez3, Francisco J
Vera-Garcia4, Mark De Ste Croix5, Gregory D Myer6,7, Francisco Ayala1
1Sports Research Centre, Miguel Hernández University of Elche, Elche, Spain
2Universidad Internacional Isabel I de Castilla, Burgos, Spain
Author Manuscript

3Operative Research Centre, Miguel Hernández University of Elche, Elche, Spain

4Department of Health Psychology, Miguel Hernandez University of Elche, Elche, Spain
5Faculty of Applied Sciences, University of Gloucestershire, Gloucestershire, UK
6Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
7Sports Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA

Abstract
Objective—We performed a systematic review and meta-analysis of epidemiological data of
injuries in professional male football.
Author Manuscript

Method—Forty-four studies have reported the incidence of injuries in football. Two reviewers
independently extracted data and assessed trial quality using the Strengthening the Reporting
of Observational Studies in Epidemiology statement and Newcastle Ottawa Scale. Studies were
combined in a pooled analysis using a Poisson random effects regression model.

Results—The overall incidence of injuries in professional male football players was 8.1 injuries/
1000 hours of exposure. Match injury incidence (36 injuries/1000 hours of exposure) was almost
10 times higher than training injury incidence rate (3.7 injuries/1000 hours of exposure). Lower
extremity injuries had the highest incidence rates (6.8 injuries/1000 hours of exposure). The most
common types of injuries were muscle/tendon (4.6 injuries/1000 hours of exposure), which were
frequently associated with traumatic incidents. Minor injuries (1–3 days of time loss) were the
most common. The incidence rate of injuries in the top 5 European professional leagues was not
Author Manuscript

different to that of the professional leagues in other countries (6.8 vs 7.6 injuries/1000 hours of
exposure, respectively).

Correspondence to: Dr Francisco Ayala, Sports Research Centre, Miguel Hernández University of Elche, Elche 03202, Spain;
[email protected].
Contributors Conceptualization: AL-V, FJV-G, MDSC, GDM, FAR. Methodology: AL-V, IRP, AG-G, FAR. Statistical analysis:
AL-V, IRP, AG-G, FAR. Writing and original draft: AL-V, IRP, FJV-G, MDSC, GDM, FAR. Writing, review and editing: AL-V, IRP,
AG-G, FJV-G, MDSC, GDM, FAR.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
 López-Valenciano et al. Page 2

Conclusions—Professional male football players have a substantial risk of sustaining injuries,

Author Manuscript

especially during matches.

INTRODUCTION
A professional football team with a 25-player squad typically suffers about 50 injuries that
cause time loss from play each season, which equates to two injuries per player per season.1

Player match availability has a strong correlation (r>0.85) with team success (ie, ranking
position, games won, goals scored, total points).2 3 Injuries are also a financial burden to
football clubs—the average cost of a player in a professional top team being injured for 1
month is calculated to be around €500.000.4

Therefore, it is important to quantify the injury incidence in professional football.5 6 There

Author Manuscript

have been a number of prospective cohort studies investigating injuries sustained by football
players since the end of the 1970s,1 and the publication of a consensus statement on injury
definitions and data collection procedures in 20067 has improved the consistency and quality
of research within the field. In the latter two decades (1998–2018) several epidemiological
studies have been published describing injury patterns over one8–11 or numerous1 12–14
seasons and during tournaments with national teams15–18 in male football players. However,
despite the large number of studies reporting the incidence and severity of football-related
injuries,1 8 19–21 no studies have combined and meta-analysed such epidemiological data.22
Identifying the most common and severe injuries as well as where (anatomical location)
and when (matches or training sessions) they usually occur would lead coaches, physical
trainers, physiotherapists and physicians to prioritise the application of specific measures to
prevent or reduce the risk of sustaining such injuries.
Author Manuscript

Therefore, we conducted a systematic review and meta-analysis quantifying the incidence of

injuies in professional male football. Our secondary purpose was to carry out subanalyses
to determine the overall effects regarding location of injuries, type of injuries, severity of
injuries, overuse and traumatic injuries, new and recurrent injuries, level of play and national
leagues (clubs) and international tournaments (national teams).

METHOD
To conduct this study, guidelines for reporting meta-analysis of observational studies
in epidemiology (Preferred Reporting Items for Systematic Reviews and Meta-Analyses
[PRISMA] guidelines) were followed.23 The PRISMA checklist is presented in online
supplementary appendix 1.
Author Manuscript

Study selection
To be included in the meta-analysis, the studies had to fulfil the following criteria: (1)
Injury must be defined in terms of time loss (ie, injury that results in a player being unable
to take full part in future football training or match play).7 24 (2) Participants had to be
professional male football players (ie, players who belong to teams engaged in professional
national football leagues).19 (3) The study had to be a full-text article published in a

Br J Sports Med. Author manuscript; available in PMC 2023 February 15.

 López-Valenciano et al. Page 3

peer-reviewed journal before March 2018. (4) Eligible studies must report either incidence
Author Manuscript

rate or prevalence among the surveyed players or provide sufficient data from which these
figures could be calculated through standardised equations. Studies using injury definitions
other than time loss were excluded. Literature reviews, abstracts, editorial commentaries and
letters to the editor were also excluded. Finally, some authors were contacted to provide
missing data or to clarify if data were duplicated in other publications. Incomplete data, or
data from an already included study, were excluded.

Search strategy
Potential studies were identified by using a systematic search process. First, the following
bibliographical databases were searched: PubMed, Scopus, Excerpta Medica Database
(EMBASE), Allied and Complementary Medicine Database (AMED), Google Scholar
and the Cochrane Library with the following search terms included in Boolean search
Author Manuscript

strategies: (soccer (tiab) OR soccer (mesh) OR football (tiab) OR football (mesh)) AND
(injury (tiab) OR injury (mesh) OR injuries (tiab) OR injuries (mesh)) AND (professional
(tiab) OR professional (mesh) OR elite (tiab) OR elite (mesh)). The search was limited to
publication dates (to 28 February 2018). Second, several specialised electronic journals were
also searched, including: British Journal of Sports Medicine, American Journal of Sports
Medicine, British Medical Journal, Scandinavian Journal of Medicine & Science in Sports,
European Journal of Sports Sciences. Finally, the reference lists of the studies recovered
were hand-searched to identify potentially eligible studies not captured by the electronic
searches.

Two reviewers independently (AL-V and IRP): (1) Screened the title, abstract and reference
list of each study to locate potentially relevant studies, and once hard copies of the screened
documents were obtained. (2) Reviewed them in detail to identify articles that met the
Author Manuscript

selection criteria. A third external reviewer (FAR) was consulted to resolve discrepancies
regarding the selection process.

Data extraction
With the aim of guaranteeing the maximum possible objectivity, a codebook was produced
that specified the standards followed in coding each of the characteristics of the studies.
The codebook can be obtained from the corresponding author on request. The moderator
variables of the eligible studies were coded and grouped into three categories: (1) General
study descriptors (eg, authors, year of publication and study design). (2) Description of the
study population (eg, sample size, age and level of play). (3) Epidemiological data (eg,
injury and exposure data, distribution of injuries by anatomical location, type of injury,
injury severity). If applicable, the authors of included studies were contacted to provide
Author Manuscript

clarifications or access to raw data. Operational definitions used in the meta-analysis are
shown in online supplementary appendix 2. Online supplementary appendix 3 also displays
the moderator variables coded separately by category.

The purpose of the current meta-analysis was to determine the overall effects of: (1)
Football-related injury incidence (overall vs training vs match injuries rates). (2) Location
of injuries (lower extremity vs trunk vs upper extremity vs head and neck). (3) Type of

Br J Sports Med. Author manuscript; available in PMC 2023 February 15.

 López-Valenciano et al. Page 4

injuries (fractures and bone stress vs joint (non-bone) and ligament vs muscle and tendon vs
Author Manuscript

contusions vs laceration and skin lesion vs central/peripheral nervous system vs undefined/

other). (4) Severity of injuries (slight/minimal (1–3 days) vs minor/mild (4–7 days) vs
moderate (8–28 days) vs major/severe (>28 days)). (5) Mechanism of injury (overuse vs
traumatic injuries). (6) New versus recurrent injuries. (7) Level of play (top-5 European
professional leagues vs other professional leagues). (8) National leagues versus international
tournaments (tournaments with national teams).

Quality assessment
The reporting quality of included studies was assessed using an adapted version of
the ‘Strengthening the Reporting of Observational Studies in Epidemiology’ (STROBE)
statement by Vom Elm et al.25 Thus, all included studies were rated on 11 specific criteria
which were derived from items 5, 6, 7, 8, 9, 12, 14 and 15 of the original checklist. This
Author Manuscript

11-item checklist provides guidance on the reporting of observational studies to facilitate

critical appraisal and interpretation of results.

Furthermore, to assess risk of bias of external validity quality, an adapted version of the
Newcastle Ottawa Scale (NOS) for cohort studies was used. The original NOS is a quality
assessment tool for cohort and case-control studies which contains eight items categorised
into three domains (selection, comparability and exposure) and uses a star rating system
to indicate the quality of a study (maximum of nine stars).26 The instrument was modified
for the purpose of this review (the incidence of injuries) and the population of football
players. Two of the eight items were deleted. Item 2 was excluded because a selection of
the non-exposed cohort was irrelevant as long as the total study population was exposed to
football play and item 5 (comparability of cohorts on the basis of the design or analysis) was
excluded because it was linked to item 2. Two new items were added to the original scale
Author Manuscript

(items 1 and 3). Therefore, the criteria adopted to assess risk of bias were: (1) Description
or type of football players. (2) Definition of injury. (3) Representativeness of the exposed
cohort. (4) Ascertainment of exposure. (5) Demonstration that the outcome of interest was
not present at the start of study. (6) Assessment of outcome. (7) Whether follow-up was
long enough for outcomes to occur. (8) Adequacy of follow-up of cohorts. An article could
be awarded a maximum of one star for each item if appropriate methods had been clearly
reported. Thus, a total of eight stars could be given to an article. The higher the number
of stars given to an article the lower the risk of bias. Similarly, modified versions of this
checklist have been used previously in systematic reviews investigating the epidemiology of
injuries in other cohorts of athletes.27 28 Online supplementary appendix 4 displays a brief
description of each item of the adapted version of the NOS tool used in this study.
Author Manuscript

The data extraction and quality assessment (including risk of bias of external validity)
were conducted by two reviewers (AL-V and IR-P). To assess the intercoder reliability
of the coding process, these two reviewers (AL-V and IR-P) coded 22 studies randomly
(50%) (including quality assessment). For the quantitative moderator variables intraclass
correlation coefficients (ICC3,1) were calculated, while for the qualitative moderator
variables Cohen’s κ coefficients were applied. On average, the ICC was 0.89 (range: 0.78–
1.0) and the κ coefficient was 0.90 (range: 0.81–1.0), which can be considered highly

Br J Sports Med. Author manuscript; available in PMC 2023 February 15.

 López-Valenciano et al. Page 5

satisfactory, as proposed by Orwin and Vevea.29 Inconsistencies between the two coders
Author Manuscript

were resolved by consensus, and when these were due to ambiguity in the coding book, this
was corrected. As before, any disagreement was resolved by mutual consent in consultation
with a third reviewer (FA).

Statistical analysis
Injury incidence rates per 1000 hours of player exposures were extracted from the included
studies. If injury incidence rates were not specifically reported, they were, if possible,
calculated from the available raw data using the following formulas:

Incidence = 1000 × ∑ injuries/ ∑ exposurehours

Incidence = n° of injuries/(n° of matches × 11 players × matchduration * ) × 1000

Author Manuscript

* Match duration, using the factor 1.5, based on standard 90 min match play. For example,
a hypothetical study reporting that a football team comprising 20 players sustained a total
of 6 injuries within the season (38 matches), the application of the second formula would
estimate an incidence of 9.6 injuries per 1000 hours of match exposure.

Data were modelled by a random effects Poisson regression model, as previously

described.30 The response variable was the number of observed injuries, offset by the log
of the number of exposure hours. A random effects term was included to account for the
correlation arising from using multiple rows of data from the same study. Factors of interest
were included as random effects. A weighting factor used was: study exposure time (hours)/
Author Manuscript

mean study exposure time (hours). The possible influence of the following variables on the
model was analysed independently through univariate and multivariate analyses: registration
period; year of the study publication, age of the players, STROBE score, NOS stars and
number of teams included in the study. Only those studies that rigorously and clearly
followed the definitions of injury described by Fuller7 were included in the subanalyses.

Heterogeneity was evaluated using the I2 statistic, which represents the percentage of total
variation across all studies due to between-study heterogeneity.31 All statistical analyses
were performed using the statistical software package R V.2.4.1 (The R Foundation for
Statistical Computing) and the ‘metafor’ package.32

For injury incidence data, the overall estimated means for each random effect factor were
obtained from the model and then back-transformed to give incidence rates, along with 95%
Author Manuscript

CIs.

RESULTS
Descriptive characteristics of the studies
A total of 2013 references were identified with all search strategies, from which 537
were excluded in the first screening as duplicates (26.6 %). One thousand three hundred
and eleven studies (65.1 %) were eliminated after reading the title and abstract. Another

Br J Sports Med. Author manuscript; available in PMC 2023 February 15.

 López-Valenciano et al. Page 6

23 studies did not report injury incidence rates or were focused on specific types
Author Manuscript

of injuries (eg, ankle sprains, hamstrings muscle strains) (1.1%). Ninety-eight did not
comply methodologically with the established criteria such as injury definition, participants
observed (amateur players or children) and data duplication (4.7 %).

The search process identified 44 articles (resulting in 56 cohort groups as seven studies
had more than one group) that met the inclusion criteria.8–10 13 15–19 21 33–66 Figure
1 shows the flow chart of the selection process of the studies. The studies were
carried out between 1989 and 2018 and comprised players from both tournaments
(world15 16 18 43 44 54 55 and continental17 21 62 tournaments) and professional football
leagues in many countries.42 46 49 52 57 66 Online supplementary appendix 5 provides a
descriptive summary of the characteristics of the included studies.

With regards to the reporting quality of the studies, the mean score obtained with the
Author Manuscript

STROBE quality scale was 7.7 (minimum: 3, maximum: 11). In general, more recent
studies (published from 2007 to 2017) had more information reported (8.5, 95% CI=7.9
to 8.8) than older (published before 2007) studies (6.3, 95% CI=6.0 to 7.0). The detailed
data are presented in online supplementary appendix 6. Regarding NOS, the mean score
obtained was 7.0 (minimum: 5, maximum: 8). The detailed data are presented in online
supplementary appendix 7.

Findings: meta-analyses
In the different meta-analyses carried out, the effect sizes exhibited a moderate to large
heterogeneity (based on the Q statistics and the I2 indices), supporting the decision of
applying random-effects models.
Author Manuscript

Neither the registration period (ie, the period of time/year when the data collection process
was carried out), nor the year of publication of the study, age, STROBE score, NOS stars
and number of teams’ variables had an impact on injury incidence rates and hence, the
subsequent subanalyses were not adjusted to these variables.

Injury incidence: overall, training and match

Thirty-four studies (43 cohorts) reported overall injury
incidence,8–10 13 17 19 21 33 35–39 41 42 44–49 51–53 56–61 63–66 30 studies (39 cohorts) reported
training injury incidence9 10 13 17 21 33 35–37 39 40 42 43 45–49 51 52 56–61 63–66 and 40 studies
(52 cohorts) reported match injury incidence9 10 13 15–18 21 33–37 39–52 54–66 that could be
combined in the meta-analysis. These studies comprised 29 991 (overall), 12 089 (training)
and 14 974 (match) injuries.
Author Manuscript

The random effect models for injury incidence showed an overall incidence of 8.1 injuries
per 1000 hours of exposure (95% CI 7.2 to 9.0, I2=99.1%), a training incidence of 3.7
injuries per 1000 hours of training exposure (95% CI 3.1 to 4.4, I2=98%) and a match
incidence of 36.0 injuries per 1000 hours of match exposure (95% CI 31.3 to 40.8,
I2=98.9%). Figures 2–4 display a summary of the reported overall, training and match injury
incidence rates of the analysed studies, respectively.

Br J Sports Med. Author manuscript; available in PMC 2023 February 15.

 López-Valenciano et al. Page 7

Location of injury
Author Manuscript

Twenty-five studies (26 cohorts) reported injury location (ie, lower extremity, trunk, upper
extremity, head and neck) and lower extremities region categories (ie, thigh, hip/groin, knee,
lower leg/Achilles tendon, ankle and foot/toe) according to Fuller et al7 which were pooled
in the meta-analysis.1 8 13 17 19 35–38 40 42 43 45 46 48 49 51 53 57 58 60 61 63 65 66 Lower
extremity injuries had the highest incidence rates (6.8 per 1000 hours of exposure, 95% CI
5.7 to 7.8, I2=98.86) compared with the other body regions. The trunk was the second most
commonly injured region (0.4 per 1000 hours of exposure, 95% CI 0.3 to 0.5, I2=97.67),
the upper extremity was the third most commonly injured region (0.3 per 1000 hours of
exposure, 95% CI 0.2 to 0.4, I2=98.32) and head and neck injuries had the lowest incidence
rates (0.2 per 1000 hours of exposure, 95% CI 0.1 to 0.2, I2=96.3).

Regarding lower extremity injuries, six anatomical regions were analysed. The mean
Author Manuscript

incidence per 1000 player hours of exposure with 95% CIs were in descending order: thigh
(1.8, 95% CI 1.5 to 2.2, I2=91.78); knee (1.2, 95% CI 1.0 to 1.4, I2=91.86); ankle (1.1, 95%
CI 0.9 to 1.2, I2=92.58); hip/groin (0.9, 95% CI 0.7 to 1.0, I2=95.32); lower leg/Achilles
tendon (0.8, 95% CI 0.6 to 1.0, I2=93.01) and foot/toe (0.4, 95% CI 0.3 to 0.5, I2=91.4)
(figure 5).

Type of injury
Twenty-four studies (26 cohorts) were included in the pooled
analysis.1 8 13 17 19 35 37–39 43 45 46 48 49 51 53 57 58 60 61 63–66 The mean incidence is
presented per 1000 hours of exposure with 95% CIs. The most common type of injury
grouping was muscle/tendon (4.6, 95% CI 3.8 to 5.4, I2=98.71), followed by contusions (1.4,
95% CI 1.1 to 1.8, I2=97.65), undefined/other injuries (0.6, 95% CI 0.3 to 0.9, I2=97.92),
joint (non-bone) and ligament (0.4, 95% CI 0.2 to 0.6, I2=98.02), fracture and bone stress
Author Manuscript

(0.2, 95% CI 0.1 to 0.3, I2=98.16), laceration and skin lesions (0.05, 95% CI 0.02 to 0.08,
I2=98.52) and the least common injury type grouping was central/peripheral nervous system
injuries (0.04, 95% CI 0.02 to 0.06; I2=98.19) (figure 6).

Severity of injury
Concerning severity of injuries, 21 studies (28 cohorts) were included in the pooled
analysis.1 10 13 17 21 33 37 40 42 43 45 46 49 51 57 58 60 61 64–66 Minimal injuries (3.1 per
1000 hours of exposure, 95% CI 2.4 to 3.9, I2=98.75) were the most usual injuries, followed
by moderate (2.0 per 1000 hours of exposure, 95% CI 1.7 to 2.4, I2=92.58), minor (1.7 per
1000 hours of exposure, 95% CI 1.4 to 2.1, I2=94.73) and severe (0.8 per 1000 hours of
exposure, 95% CI 0.6 to 1.0, I2=91.63) injuries (online supplementary appendix 8).
Author Manuscript

Mechanism of injury
Twenty studies (26 cohorts) were involved in the meta-analysis to compare overuse injuries
versus traumatic injuries.8 9 17 19 21 35 38 39 42 45 46 49 51 57 58 60 61 64–66 The incidence in
traumatic injuries (5.9, 95% CI 4.7 to 7.1, I2=99.32) was higher than in overuse injuries (2.4,
95% CI 1.9 to 3.0, I2=98.31).

Br J Sports Med. Author manuscript; available in PMC 2023 February 15.

 López-Valenciano et al. Page 8

New versus recurrent injuries

Author Manuscript

Fifteen studies (21 cohorts) were included in an analysis which compared the incidence of
new versus recurrent injuries.13 21 35 39 42 43 45 46 51 52 57 58 61 64 66 The incidence rate
of new injuries (7.0 per 1000 hours of exposure, 95% CI 6.0 to 8.1, I2=98.84) was higher
than recurrent injuries incidence rate (1.3 per 1000 hours of exposure, 95% CI 0.8 to 1.8,
I2=98.53).

Level of play
For level of play, 32 studies were divided into two groups: (1) Top-5 European professional
leagues as ranked by Union of European Football Associations (UEFA) in 2018 (https://
www.uefa.com/memberassociations/uefarankings/index.html) (La Liga (Spain), Premier
League (England), Serie A (Italy), Bundesliga (Germany) and Ligue1 (France)). (2) Other
professional leagues in the world (outside the top-5 European professional leagues). Seven
Author Manuscript

studies were performed in clubs belonging to the top-5 European professional leagues and
reported overall13 40 41 49 57 60 61 training13 40 49 57 60 61 and match13 40 41 49 57 60 61
incidence rates, respectively. Alternatively, 25 studies were conducted in the professional
leagues outside of the top-5 European professional leagues, and also reported
overall,8 10 19 35–39 46–48 51–53 56 58 59 63–66 training10 35–37 39 46–48 51 52 56 58 59 63–66and
match10 34–37 39 46–48 50–52 56 58 59 63–66 incidence rates. The overall incidence rate in
professional leagues was not significantly different than in the top-5 European leagues (7.6,
95% CI 6.2 to 9.0 vs 6.8, 95% CI 5.8 to 7.9, respectively). The mean incidence rates in
training and match were in descending order: top-5 European leagues match: 35.5 (30.0
to 40.9, I2=90.23), other professional leagues match: 31.9 (23.2 to 40.6, I2=97.23), other
professional leagues training: 3.9 (2.9 to 5.0, I2=98.01) and top-5 European professional
leagues training: 3.6 (3.2 to 4.0, I2=91.23).
Author Manuscript

National leagues versus international tournaments

For this comparison, 44 studies were divided into two groups: (1) National leagues—
studies in football clubs of professional leagues. (2) International tournaments—studies
in national teams during international tournaments. Twenty-eight, 24 and 27 studies
carried out in football clubs reported overall,8 10 13 19 35–40 42 46–49 51–53 56–61 63–66
training,10 13 35–37 39 40 42 46–49 51 52 56–61 63–66 and match10 13 34–37 39–42 46–52 56–61 63–66
incidence rates. On the other hand, 6, 6 and 13 studies in national teams reported
overall,9 17 21 33 43 45 training9 17 21 33 43 45 and match9 15–18 21 33 43–45 55 62 incidence
rates. Incidence rates in international tournaments were higher than in national leagues (9.8,
95% CI 8.8 to 10.8 vs 7.5, 95% CI 6.5 to 8.4, for international tournaments and national
leagues). In particular, the mean incidence rates in training and match were in descending
Author Manuscript

order: international match: 41.1 (33.9 to 48.2, I2=90.69); national match: 32.3 (26.7 to 37.9,
I2=96.43); national training: 3.8 (3.2 to 4.5, I2=98.37); and international training: 3.5 (2.2 to
4.7, I2=91.71).

DISCUSSION
The purposes of this study were to perform a systematic review and meta-analysis
quantifying the incidence of injuries in professional male football as well as to conduct

Br J Sports Med. Author manuscript; available in PMC 2023 February 15.

 López-Valenciano et al. Page 9

subanalyses to determine the overall effects regarding location of injuries, type of injuries,
Author Manuscript

severity of injuries, overuse and traumatic injuries, new and recurrent injuries, level of play
and national leagues (clubs) and international tournaments (national teams).

Injury incidence: overall, training and match

This meta-analysis indicates that the incidence rate per 1000 hours of exposure for
professional male football players (8.1 injuries per 1000 hours of exposure) is lower than
the injury incidence rate provided for professional male rugby players (12.6 injuries per
1000 hours of exposure).67 The incidence rates in the current meta-analysis are similar to
injury incidence rates provided in individual studies for amateur football players (5.1–10.9
injuries per 1000 hours of exposure),68–70 college ice hockey players (9.1 injuries per 1000
hours of exposure)71 and senior handball players (6.3 injuries per 1000 hours of exposure).72
Fortunately, although injuries occur frequently in professional football players, the majority
Author Manuscript

appear to be of minimal severity (1–3 days lost from sport play).

In line with most team sports (eg, basketball,73 handball,72 rugby)67 match/game injury
incidence in football was notably higher (almost 10 times) than the injury rate obtained
for training sessions. A number of studies have attributed these differences in injury
incidence rates between match and training to several factors, including the higher physical
demands on players during matches in comparison with training sessions, the number of
contacts and collisions during matches, and fatigue generated during the course of the
match.1 74 75 Furthermore, the variability and uncertainly generated in the players when
competing against rivals in a match compared with teammates in training may potentiate
these differences. Although still under debate, it has been suggested that training session
design (ie, workload, intensity, duration), when possible, should mimic match demands so
that players are better prepared for what they face during matches.76 Although the limited
Author Manuscript

number of studies published did not permit us to describe the pattern of injury incidence
during the course of a football match, the current evidence shows that the incidence rates
of some injuries tend to increase towards the end of each half.1 14 16 44 74 77 The finding
of a higher incidence of injuries in the second part of each half in comparison with other
match periods may indicate that fatigue is implicated in injury aetiology, however, factors
contributing to this (eg, hydration, nutrition, neuromuscular compromise and biomechanical
alterations to technique) require further investigation.

Location of injury
As expected, lower extremity injuries were by far the most frequent location for an injury
with an incidence rate of 6.8 injuries per 1000 hours of exposure. The thigh was the
most commonly injured anatomical region followed by the knee. Furthermore, the most
Author Manuscript

common type of injury grouping was muscle/tendon injuries. Due to the lack of studies
reporting incidence rates separately for different muscle groups (eg, gluteus, hamstrings,
quadriceps, abductors, adductors, triceps surae), a subanalysis aimed at identifying the most
injured muscle group was not possible. However, previous epidemiological studies have
consistently reported that hamstring muscles are the muscle group most frequently injured
in professional football players.66 74 78 As previous studies exploring the location and type
of football-related injuries have only reported incidence rates and not the average number

Br J Sports Med. Author manuscript; available in PMC 2023 February 15.

 López-Valenciano et al. Page 10

of days lost from football (time loss), it was not possible for us to calculate the injury
Author Manuscript

burden (the cross-product of severity (consequences) and incidence (likelihood)) to build

a risk matrix. The risk matrix would have helped to identify the importance of each type
of football-related injury and may provide information to help prioritise injury prevention
measures used in professional football environments. Recently, Bahr et al79 built a risk
matrix based on data from the UEFA Elite Club Injury Study and suggested that injury
reduction in the areas of the hamstring, groin, knee and ankle are priorities for coaching,
medical and fitness staff, while concussions represent less of a health burden. According
to Ekstrand et al,80 the measures designed to reduce the injury burden should address the
traditionally proposed modifiable injury risk factors (eg, eccentric strength deficits,81–83
poor flexibility,84 85 altered muscle architecture,86 87 player load and match frequency)8 88
and some new external factors such as the stability of the club in terms of coaching, medical
staff and management, players adherence and coach compliance to the injury prevention
programme.89
Author Manuscript

Overuse versus traumatic injuries

In this study most of the football-related injuries had a traumatic mechanism, with an
incidence rate of 5.9 injuries per 1000 hours of exposure, twice that of the incidence
reported in overuse injuries (2.4 injuries per 1000 hours of exposure). In particular, being
tackled or colliding with an opponent (ie, during a jump) appear to be the most common
injury incidents, representing approximately 50% of all traumatic injuries, followed closely
by the injury incidents caused during non-contact actions such as sprinting and cutting (30%
of all cases of traumatic injuries).90 As it has been documented for young players,91 92
the application of football-specific neuromuscular training programmes with the aim of
optimising players’ motor competency, joint stability and delaying the onset of fatigue might
Author Manuscript

reduce the relative risk of injury due to acute overload of soft tissues.

New versus recurrent injuries

As expected, recurrent injuries incidence is lower than the new injuries rate (1.3 vs 7.0
injuries per 1000 hours of exposure). However, the recurrent rate identified in the present
study may be considered high. It has been recently shown that most recurrent injuries
(mainly lower extremity muscle and tendon injuries) occur within 2 months after return
to play.52 This may reflect a premature return to train/play and incomplete or inadequate
rehabilitation. The lack of evidence-based criteria for a safe return to train/play alongside
the fact that team managers and coaches may be tempted to let injured players return to
play important matches or to let them play with ongoing minor symptoms might be two
reasons behind the high recurrent injuries incidence rates. Future studies should extend our
Author Manuscript

current knowledge in relation to improving the decision-making process for a safe return
to training/play by developing learning algorithms or artificial intelligence-based models
that allow the identification of when a player is fully and effectively rehabilitated before
returning to training/play.93

Level of play
The results of this study also highlight that the incidence rates overall, during training
and match play were similar between top-5 level European leagues and the rest of the

Br J Sports Med. Author manuscript; available in PMC 2023 February 15.

 López-Valenciano et al. Page 11

professional leagues. These findings suggest that although there may be differences in the
Author Manuscript

number and density (ie, match congestion) of matches played across the season between
teams engaged in top-5 level European leagues and teams from other professional leagues,
that this does not lead to a greater injury incidence rate. These findings were unexpected
because a number of teams engaged in top-5 level European leagues must face a higher
recurrence of exposure to periods of short (i.e. ≤3 days elapsed between consecutive
match exposures) and long-term match congestion (i.e. >7.5 hours of match play exposure
within 30 days) across the season (due to organisational reasons of their national leagues
and their simultaneous participation in other national (eg, FA Cup and Football League
Cup in England) and European (ie, UEFA Europa League and UEFA Champion League)
tournaments) in comparison with their counterparts from other (eg, Scandinavian leagues),
but not all, professional leagues94 and hence, a priori we predicted a higher incidence
of injuries. However, a recently published 14 years prospective study, with 2672 male
Author Manuscript

professional football players included and more than 130 000 match observations, found
no associations between total match injury rates and high short-term and long-term match
congestion periods95 which is in line with the results in the current meta-analysis. A possible
explanation for these similar match incidence rates between top-5 level European leagues
and the rest of the professional leagues could be linked to player rotation policies carried out
in top-level teams (eg, sporadic exposure over the season, players only competing in one out
of two matches in cycles played in a short time frame,<75 min exposure time) that might
have diluted the real risk of injury.96

National leagues versus international tournaments

Finally, the present meta-analysis has also shown that the incidence rate during international
matches (41.1 injuries per 1000 hours of exposure) was higher than during national matches
Author Manuscript

(32.3 injuries per 1000 hours of exposure). The higher density of matches played, the mental
stress and anxiety generated in the players, and the fact that international competitions are
usually played during summer periods (at the end of a long season where accumulated
fatigue may play a part and during hot and dry climate conditions) have been suggested as
contributing factors for this increase in the number of injuries.94 97

LIMITATIONS
Like other meta-analyses conducted in sports medicine settings,67 98 variations in injury and
severity definitions associated with older studies resulted in heterogeneous estimates of the
main meta-analysis. Only those studies that rigorously and clearly followed the definitions
of injury described by Fuller7 were included in the subanalyses. Also when different
epidemiological data were used (eg, hours of athlete exposure, total number of injuries,
Author Manuscript

number of matches played) and therefore various methods of data collection, we applied
standardised formulas to account for this discrepancy. Nevertheless, even when our inclusion
criteria for subanalysis and standardised formulas were applied, the degree of inconsistency
of the results across studies was still very high (I1 >90%). Consequently, variations in
injury definitions and lack of uniform data collection methods may not have been the
unique sources of inconsistency in the results. Other potential sources of inconsistency
may have been the differences existing among the national leagues in terms of climatic

Br J Sports Med. Author manuscript; available in PMC 2023 February 15.

 López-Valenciano et al. Page 12

regions (cooler and warmer areas),37 periods of fixed match congestion,41 42 numbers of
matches and in-season breaks49 as well as the level of professionalism.52 Additionally, the
Author Manuscript

sample size of studies included was not sufficient to investigate interactive effects within
factors (eg, playing position by level of play) or whether injury rates are associated with
a violation of the competition rules (a variable that has not been thoroughly explored).
This could, for example, help to assess whether the protective equipment used by players
(shin pads) reduces injury risk or if other equipment is needed for certain positions (eg, a
helmet for the goalkeeper to protect themselves against concussions). Furthermore, the lack
of studies that reported the average number of days lost from football, caused by specific
types of injuries, did not allow us to present data on injury burden. Another limitation that
should be mentioned is that this study was not eligible for inclusion in the International
Prospective Register of Systematic Reviews database because the systematic review had
progressed beyond the point of completing data extraction when the official registration
Author Manuscript

process was addressed. Consequently, it was not possible to make a comparison between
the predictive outcomes and those finally published in order to analyse any discrepancy. In
our analysis separate incidence rates reported in studies that covered multiple seasons or
cups were considered as independent when multiple comparisons were conducted. In this
instance the same player may have been counted more than once over the different seasons.
However, for each separate incidence rate recorded, the same player was counted only one
time. Unfortunately only one author corresponded when asked for additional information
subsequently limiting the data we had access to.

CONCLUSIONS
Professional male football players are exposed to a substantial risk of sustaining injuries,
especially during matches. Although most injuries had a traumatic mechanism (injuries
Author Manuscript

with sudden onset and known cause), fortunately most of them appear to be of minimal
severity. As might be expected, the lower extremity is more frequently injured, and the most
common type of injury is muscle/tendon strain. Recurrent injuries were less frequent than
new injuries, although re-injury rates have implications for return to train/play management.
Future studies should focus on introducing and evaluating preventative measures that
target the most common diagnoses, namely, muscle/tendon injuries highlighted in this meta-
analysis, in order to reduce the number and severity of injuries within male professional
football players.

Supplementary Material
Refer to Web version on PubMed Central for supplementary material.
Author Manuscript

Funding
AL-V was supported by a predoctoral grant given by Ministerio de Educación, Cultura y Deporte (FPU) from
Spain. FAR was supported by a postdoctoral grant given by Seneca Foundation (postdoctoral fellowships funded by
the regional sub program focuses on the postdoctoral development, 20366/PD/17) from Spain.

Br J Sports Med. Author manuscript; available in PMC 2023 February 15.

 López-Valenciano et al. Page 13

REFERENCES
Author Manuscript

1. Ekstrand J, Hägglund M, Waldén M. Injury incidence and injury patterns in professional football:
the UEFA injury study. Br J Sports Med 2011;45:553–8. [PubMed: 19553225]
2. Hägglund M, Waldén M, Magnusson H, et al. Injuries affect team performance negatively in
professional football: an 11-year follow-up of the UEFA champions League injury study. Br J
Sports Med 2013;47:738–42. [PubMed: 23645832]
3. Eirale C, Tol JL, Farooq A, et al. Low injury rate strongly correlates with team success in Qatari
professional football. Br J Sports Med 2013;47:807–8. [PubMed: 22904292]
4. Ekstrand J Keeping your top players on the pitch: the key to football medicine at a professional
level. Br J Sports Med 2013;47:723–4.
5. Finch C A new framework for research leading to sports injury prevention. Journal of Science and
Medicine in Sport 2006;9:3–9. [PubMed: 16616614]
6. van Mechelen W, Hlobil H, Kemper HCG. Incidence, severity, aetiology and prevention of sports
injuries. Sports Medicine 1992;14:82–99. [PubMed: 1509229]
7. Fuller CW, Ekstrand J, Junge A, et al. Consensus statement on injury definitions and data
Author Manuscript

collection procedures in studies of football (soccer) injuries. Scand J Med Sci Sports 2006;16:83–
92. [PubMed: 16533346]
8. Arnason A, Sigurdsson SB, Gudmundsson A, et al. Risk factors for injuries in football. Am J Sports
Med 2004;32(1_suppl):5–16.
9. Ekstrand J, Waldén M, Hägglund M. Risk for injury when playing in a National football team.
Scand J Med Sci Sports 2004;14:34–8. [PubMed: 14723786]
10. Hägglund M, Waldén M, Ekstrand J. Exposure and injury risk in Swedish elite football: a
comparison between seasons 1982 and 2001. Scand J Med Sci Sports 2003;13:364–70. [PubMed:
14617057]
11. Waldén M, Hägglund M, Ekstrand J. UEFA champions League study: a prospective study of
injuries in professional football during the 2001–2002 season. British Journal of Sports Medicine
2005;39:542–6. [PubMed: 16046340]
12. Hägglund M, Waldén M, Ekstrand J. Previous injury as a risk factor for injury in elite football: a
prospective study over two consecutive seasons. British Journal of Sports Medicine 2006;40:767–
Author Manuscript

72. [PubMed: 16855067]

13. Hawkins RD, Fuller CW. A prospective epidemiological study of injuries in four English
professional football clubs. British Journal of Sports Medicine 1999;33:196–203. [PubMed:
10378073]
14. Hawkins RDet al. The association football medical research programme: an audit of injuries in
professional football. Br J Sports Med 2001;35:43–7. [PubMed: 11157461]
15. Junge A, Dvorak J, Graf-Baumann T. Football injuries during the World Cup 2002. Am J Sports
Med 2004;32(1_suppl):23–7.
16. Junge A, Dvorak J, Graf-Baumann T, et al. Football injuries during FIFA Tournaments and the
Olympic games, 1998–2001. Am J Sports Med 2004;32(1_suppl):80–9.
17. Waldén M, Hägglund M, Ekstrand J. Football injuries during European championships 2004–2005.
Knee Surg Sports Traumatol Arthrosc 2007;15:1155–62. [PubMed: 17375283]
18. Junge A, Dvořák J. Football injuries during the 2014 FIFA World Cup. Br J Sports Med
2015;49:599–602. [PubMed: 25878077]
Author Manuscript

19. Ekstrand J, Hägglund M, Fuller CW. Comparison of injuries sustained on artificial turf and grass
by male and female elite football players. Scand J Med Sci Sports 2011;21:824–32. [PubMed:
20456680]
20. Hägglund M, Waldén M, Ekstrand J. Injuries among male and female elite football players.
Scand J Med Sci Sports 2009;19:819–27. [PubMed: 18980604]
21. Hägglund M, Waldén M, Ekstrand J. UEFA injury study--an injury audit of European
Championships 2006 to 2008. British Journal of Sports Medicine 2009;43:483–9. [PubMed:
19246461]

Br J Sports Med. Author manuscript; available in PMC 2023 February 15.

 López-Valenciano et al. Page 14

22. Burke LM, Peeling P. Methodologies for investigating performance changes with supplement use.
Int J Sport Nutr Exerc Metab 2018;20:1–11.
Author Manuscript

23. Hutton B, Catalá-López F, Moher D. The PRISMA statement extension for systematic
reviews incorporating network meta-analysis: PRISMA-NMA. Medicina Clínica 2016;147:262–6.
[PubMed: 27040178]
24. Hägglund Met al. Methods for epidemiological study of injuries to professional football players:
developing the UEFA model. Br J Sports Med 2005;39:340–6. [PubMed: 15911603]
25. von Elm E, Altman DG, Egger M, et al. The strengthening the reporting of observational studies
in epidemiology (STROBE) statement: guidelines for reporting observational studies. International
Journal of Surgery 2014;12:1495–9. [PubMed: 25046131]
26. Wells G, Shea B, O’Connell D, et al. The Newcastle-Ottawa scale (NOS) for assessing the quality
of nonrandomised studies in metaanalyses Canada: Department of Epidemiology and Community
Medicine, University of Ottawa, Canada. University of Ottawa, 2013.
27. Saragiotto BT, Yamato TP, Hespanhol Junior LC, et al. What are the main risk factors for
running-related injuries? Sports Med 2014;44:1153–63. [PubMed: 24809248]
28. Videbæk S, Bueno AM, Nielsen RO, et al. Incidence of Running-Related Injuries Per 1000 h
Author Manuscript

of running in Different Types of Runners: A Systematic Review and Meta-Analysis. Sports Med
2015;45:1017–26. [PubMed: 25951917]
29. Orwin RG, Vevea JL. Evaluating coding decisions. The handbook of research synthesis and
meta-analysis 2009;2:177–203.
30. Bagos PG, Nikolopoulos GK. Mixed-effects poisson regression models for meta-analysis of
follow-up studies with constant or varying durations. Int J Biostat 2009;5. [PubMed: 20104258]
31. Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta-analysis. Statist. Med
2002;21:1539–58.
32. Viechtbauer W Conducting Meta-Analyses in R with the metafor Package. J Stat Softw 2010;36:1–
48.
33. Almutawa M, Scott M, George KP, et al. The incidence and nature of injuries sustained on grass
and 3rd generation artificial turf: A pilot study in elite Saudi National Team footballers. Physical
Therapy in Sport 2014;15:47–52. [PubMed: 23791754]
34. Andersen TEet al. Video analysis of injuries and incidents in Norwegian professional football.
Author Manuscript

British Journal of Sports Medicine 2004;38:626–31. [PubMed: 15388553]

35. Árnason Á, Gudmundsson Á, Dahl HA, et al. Soccer injuries in Iceland. Scand J Med Sci Sports
1996;6:40–5. [PubMed: 8680943]
36. Arnason A, Engebretsen L, Bahr R. No effect of a video-based awareness program on the rate of
soccer injuries. Am J Sports Med 2005;33:77–84. [PubMed: 15611002]
37. Bayne H, Schwellnus M, van Rensburg DJ, et al. Incidence of injury and illness in South African
professional male soccer players: a prospective cohort study. J Sports Med Phys Fitness 2018;58.
38. Bjørneboe J, Bahr R, Andersen TE. Gradual increase in the risk of match injury in Norwegian
male professional football: a 6-year prospective study. Scand J Med Sci Sports 2014;24:189–96.
[PubMed: 22582981]
39. Calligeris T, Burgess T, Lambert M. The incidence of injuries and exposure time of professional
football Club players in the premier soccer League during football season. S Afr J SM
2015;27:16–19.
40. Carling C, McCall A, Le Gall F, et al. The impact of in-season national team soccer play on
injury and player availability in a professional Club. Journal of Sports Sciences 2015;33:1751–7.
Author Manuscript

[PubMed: 25751636]
41. Carling C, Orhant E, LeGall F. Match injuries in professional soccer: inter-seasonal variation and
effects of competition type, match congestion and positional role. Int J Sports Med 2010;31:271–6.
[PubMed: 20166007]
42. Dupont G, Nedelec M, McCall A, et al. Effect of 2 soccer matches in a week on physical
performance and injury rate. Am J Sports Med 2010;38:1752–8. [PubMed: 20400751]
43. Dvorak J, Junge A, Derman W, et al. Injuries and illnesses of football players during the 2010 FIFA
World Cup. British Journal of Sports Medicine 2011;45:626–30. [PubMed: 21257668]

Br J Sports Med. Author manuscript; available in PMC 2023 February 15.

 López-Valenciano et al. Page 15

44. Dvorak J, Junge A, Grimm K, et al. Medical report from the 2006 FIFA World Cup Germany.
British Journal of Sports Medicine 2007;41:578–81. [PubMed: 17510228]
Author Manuscript

45. Eirale C, Hamilton B, Bisciotti G, et al. Injury epidemiology in a National football team of the
Middle East. Scand J Med Sci Sports 2012;22:323–9. [PubMed: 20874859]
46. Eirale C, Tol JL, Smiley F, et al. Does Ramadan affect the risk of injury in professional football?
Clinical Journal of Sport Medicine 2013;23:261–6. [PubMed: 23528844]
47. Ekstrand J, Tropp H. The incidence of ankle sprains in soccer. Foot & Ankle 1990;11:41–4.
[PubMed: 2210532]
48. Engström B, Forssblad M, Johansson C, et al. Does a major knee injury definitely sideline an elite
soccer player? Am J Sports Med 1990;18:101–5. [PubMed: 2301681]
49. Kad F, Faude O, Lensch J, et al. Injury characteristics in the German professional male soccer
leagues after a shortened winter break. J Athl Train 2014;49:786–93. [PubMed: 25365132]
50. Gouttebarge V, Hughes Schwab BA, Vivian A, et al. Injuries, matches missed and the influence
of minimum Medical standards in the A-League professional football: a 5-year prospective study.
Asian J Sports Med 2016;7.
51. Hägglund M, Waldén M, Ekstrand J. Injury incidence and distribution in elite football-a
Author Manuscript

prospective study of the Danish and the Swedish top divisions. Scand J Med Sci Sports
2005;15:21–8. [PubMed: 15679568]
52. Hägglund M, Waldén M, Ekstrand J. Injury recurrence is lower at the highest professional football
level than at national and amateur levels: does sports medicine and sports physiotherapy deliver?
Br J Sports Med 2016;50:751–8. [PubMed: 27015858]
53. Hassabi M, Mohammad-Javad Mortazavi S, Giti M-R, et al. Injury profile of a professional soccer
team in the premier League of Iran. Asian J Sports Med 2010;1.
54. Hawkins RD, Fuller CW. Risk assessment in professional football: an examination of accidents and
incidents in the 1994 World Cup finals. Br J Sports Med 1996;30:165–70. [PubMed: 8799605]
55. Junge A, Dvorak J. Injury surveillance in the world football Tournaments 1998–2012. Br J Sports
Med 2013;47:782–8. [PubMed: 23632746]
56. Kristenson K, Bjørneboe J, Waldén M, et al. The Nordic football injury audit: higher injury rates
for professional football clubs with third-generation artificial turf at their home venue. Br J Sports
Med 2013;47:775–81. [PubMed: 23760552]
Author Manuscript

57. Larruskain J, Lekue JA, Diaz N, et al. A comparison of injuries in elite male and female football
players: a five-season prospective study. Scand J Med Sci Sports 2018;28:237–45. [PubMed:
28207979]
58. JW-Y L, Mok K-M, Chan HC-K, et al. A prospective epidemiological study of injury incidence
and injury patterns in a Hong Kong male professional football League during the competitive
season. Asia Pac J Sports Med Arthrosc Rehabil Technol 2014;1:119–25.
59. Nielsen AB, Yde J. Epidemiology and traumatology of injuries in soccer. Am J Sports Med
1989;17:803–7. [PubMed: 2516415]
60. Noya Salces J, Gómez-Carmona PM, Gracia-Marco L, et al. Epidemiology of injuries in first
division Spanish football. J Sports Sci 2014b;32:1263–70. [PubMed: 24787731]
61. Noya Salces J, Gomez-Carmona PM, Moliner-Urdiales D, et al. An examination of injuries in
Spanish professional soccer League. J Sports Med Phys Fitness 2014a;54:765–71. [PubMed:
25350033]
62. Pedrinelli A, Filho GARdaC, Thiele ES, et al. Epidemiological study on professional football
injuries during the 2011 CopA America, Argentina. Revista Brasileira de Ortopedia 2013;48:131–
Author Manuscript

6. [PubMed: 31211118]
63. Poulsen TD, Freund KG, Madsen F, et al. Injuries in high-skilled and low-skilled soccer: a
prospective study. British Journal of Sports Medicine 1991;25:151–3. [PubMed: 1777784]
64. Reis GF, Santos TRT, Lasmar RCP, et al. Sports injuries profile of a first division Brazilian soccer
team: a descriptive cohort study. Braz. J. Phys. Ther 2015;19:390–7. [PubMed: 26537809]
65. Shalaj I, Tishukaj F, Bachl N, et al. Injuries in professional male football players in Kosovo: a
descriptive epidemiological study. BMC Musculoskelet Disord 2016;17.

Br J Sports Med. Author manuscript; available in PMC 2023 February 15.

 López-Valenciano et al. Page 16

66. Stubbe JH, van Beijsterveldt A-MMC, van der Knaap S, et al. Injuries in professional male soccer
players in the Netherlands: a prospective cohort study. J Athl Train 2015;50:211–6. [PubMed:
Author Manuscript

25531144]
67. Williams S, Trewartha G, Kemp S, et al. A meta-analysis of injuries in senior men’s professional
Rugby Union. Sports Med 2013;43:1043–55. [PubMed: 23839770]
68. van Beijsterveldt AMCA-M, Stubbe JH, Schmikli SL, et al. Differences in injury risk and
characteristics between Dutch amateur and professional soccer players. J Sci Med Sport
2015;18:145–9. [PubMed: 24636127]
69. Mallo J, González P, Veiga S, et al. Injury incidence in a Spanish sub-elite professional football
team: a prospective study during four consecutive seasons. J Sports Sci Med 2011;10.
70. Peterson L, Junge A, Chomiak J, et al. Incidence of football injuries and complaints in different
age groups and skill-level groups. Am J Sports Med 2000;28(5_suppl):51–7.
71. Schick DM, Meeuwisse WH. Injury rates and profiles in female ice hockey players. Am J Sports
Med 2003;31:47–52. [PubMed: 12531756]
72. Moller M, Attermann J, Myklebust G, et al. Injury risk in Danish youth and senior elite handball
using a new SMS text messages approach. Br J Sports Med 2012;46:531–7. [PubMed: 22554848]
Author Manuscript

73. Podlog L, Buhler CF, Pollack H, et al. Time trends for injuries and illness, and their relation
to performance in the National Basketball association. Journal of Science and Medicine in Sport
2015;18:278–82. [PubMed: 24908360]
74. Ekstrand J, Hägglund M, Waldén M. Epidemiology of muscle injuries in professional football
(soccer). Am J Sports Med 2011;39:1226–32. [PubMed: 21335353]
75. Bangsbo J, Mohr M, Krustrup P. Physical and metabolic demands of training and match-play in the
elite football player. Journal of Sports Sciences 2006;24:665–74. [PubMed: 16766496]
76. Gabbett TJ. The training-injury prevention paradox: should athletes be training smarter and harder?
Br J Sports Med 2016;50:273–80. [PubMed: 26758673]
77. Rahnama N, Reilly T, Lees A. Injury risk associated with playing actions during competitive
soccer. Br J Sports Med 2002;36:354–9. [PubMed: 12351333]
78. Hägglund M. Epidemiology and prevention of football injuries Institutionen för hälsa och
samhälle, 2007.
79. Bahr R, Clarsen B, Ekstrand J. Why we should focus on the burden of injuries and illnesses, not
Author Manuscript

just their incidence. Br J Sports Med 2017.

80. Ekstrand J, Waldén M, Hägglund M. Hamstring injuries have increased by 4% annually in men’s
professional football, since 2001: a 13-year longitudinal analysis of the UEFA Elite Club injury
study. Br J Sports Med 2016;50:731–7. [PubMed: 26746908]
81. Croisier J-L, Ganteaume S, Binet J, et al. Strength imbalances and prevention of hamstring injury
in professional soccer players. Am J Sports Med 2008;36:1469–75. [PubMed: 18448578]
82. Petersen J, Thorborg K, Nielsen MB, et al. Preventive effect of eccentric training on acute
hamstring injuries in men’s soccer: a cluster-randomized controlled trial. Am J Sports Med
2011;39:2296–303. [PubMed: 21825112]
83. van Dyk N, Bahr R, Whiteley R, et al. Hamstring and quadriceps isokinetic strength deficits are
weak risk factors for hamstring strain injuries. Am J Sports Med 2016;44:1789–95. [PubMed:
27002102]
84. Henderson G, Barnes CA, Portas MD. Factors associated with increased propensity for hamstring
injury in English premier League soccer players. Journal of Science and Medicine in Sport
2010;13:397–402. [PubMed: 19800844]
Author Manuscript

85. Fousekis K, Tsepis E, Poulmedis P, et al. Intrinsic risk factors of non-contact quadriceps and
hamstring strains in soccer: a prospective study of 100 professional players. British Journal of
Sports Medicine 2011;45:709–14. [PubMed: 21119022]
86. Lees A, Nolan L. The biomechanics of soccer: a review. Journal of Sports Sciences 1998;16:211–
34. [PubMed: 9596356]
87. Timmins RG, Bourne MN, Shield AJ, et al. Short biceps femoris fascicles and eccentric knee
flexor weakness increase the risk of hamstring injury in elite football (soccer): a prospective cohort
study. Br J Sports Med 2016;50:1524–35. [PubMed: 26675089]

Br J Sports Med. Author manuscript; available in PMC 2023 February 15.

 López-Valenciano et al. Page 17

88. Rahnama N, Reilly T, Lees A, et al. Muscle fatigue induced by exercise simulating the work rate of
competitive soccer. Journal of Sports Sciences 2003;21:933–42. [PubMed: 14626373]
Author Manuscript

89. McCall A, Dupont G, Ekstrand J. Injury prevention strategies, coach compliance and player
adherence of 33 of the UEFA Elite Club Injury Study teams: a survey of teams’ head medical
officers. Br J Sports Med 2016;50:725–30. [PubMed: 26795611]
90. Wong P, Hong Y. Soccer injury in the lower extremities. British Journal of Sports Medicine
2005;39:473–82. [PubMed: 16046325]
91. Emery CA, Meeuwisse WH. The effectiveness of a neuromuscular prevention strategy to reduce
injuries in youth soccer: a cluster-randomised controlled trial. British Journal of Sports Medicine
2010;44:555–62. [PubMed: 20547668]
92. Silvers H, Mandelbaum B, Bizzini M, et al. The efficacy of the FIFA 11+ program in the collegiate
male soccer player (USA). Br J Sports Med 2014;48:662.1–662.
93. van der Horst N Preventing hamstring injuries in football through enhanced exercise and RTP
strategies. Br J Sports Med 2018;0:1–2.
94. Bengtsson H, Ekstrand J, Hägglund M. Muscle injury rates in professional football increase with
fixture congestion: an 11-year follow-up of the UEFA champions League injury study. Br J Sports
Author Manuscript

Med 2013;47:743–7. [PubMed: 23851296]

95. Bengtsson H, Ekstrand J, Waldén M, et al. Muscle injury rate in professional football is higher
in matches played within 5 days since the previous match: a 14-year prospective study with more
than 130 000 match observations. Br J Sports Med 2017.
96. Carling C, McCall A, Le Gall F, et al. The impact of short periods of match congestion on injury
risk and patterns in an elite football Club. Br J Sports Med 2016;50:764–8. [PubMed: 26682867]
97. Ekstrand J, Waldén M, Hägglund M. A congested football calendar and the wellbeing of players:
correlation between match exposure of European footballers before the World Cup 2002 and
their injuries and performances during that World Cup. British Journal of Sports Medicine
2004;38:493–7. [PubMed: 15273193]
98. Lystad RP, Gregory K, Wilson J. The epidemiology of injuries in mixed martial arts a systematic
review and meta-analysis. Orthop J Sports Med 2014;2.
Author Manuscript
Author Manuscript

Br J Sports Med. Author manuscript; available in PMC 2023 February 15.

 López-Valenciano et al. Page 18
Author Manuscript

What is already known?

• Injuries are one of the biggest problems in modern football.

• Some types of injuries have increased in the past few decades.

• Professional male football players are exposed to a substantial risk of

sustaining injuries, especially during matches.

What are the new findings?

• Match injury incidence is almost 10 times higher than the training injury
incidence rate.

• Although most injuries have a traumatic mechanism, most appear to be of

minimal severity.
Author Manuscript

• It is confirmed that the lower extremity is more frequently injured, and the
most common types of injuries are muscle/tendon strains.

• Injury incidence rates between the top-5 level European leagues and the rest
of the professional leagues overall, in training and match play are similar.
Author Manuscript
Author Manuscript

Br J Sports Med. Author manuscript; available in PMC 2023 February 15.

 López-Valenciano et al. Page 19
Author Manuscript
Author Manuscript
Author Manuscript

Figure 1.
Flow chart of the selection of studies for the meta-analysis.
Author Manuscript

Br J Sports Med. Author manuscript; available in PMC 2023 February 15.

 López-Valenciano et al. Page 20
Author Manuscript
Author Manuscript
Author Manuscript

Figure 2.
Overall injury incidence forest plot with 95% CIs. EC, Europe tournament; NT, national
team; U, under; WC, world tournament.
Author Manuscript

Br J Sports Med. Author manuscript; available in PMC 2023 February 15.

 López-Valenciano et al. Page 21
Author Manuscript
Author Manuscript
Author Manuscript

Figure 3.
Training injury incidence forest plot with 95% CIs. EC, Europe tournament; NT, national
team; U, under; WC, world tournament.
Author Manuscript

Br J Sports Med. Author manuscript; available in PMC 2023 February 15.

 López-Valenciano et al. Page 22
Author Manuscript
Author Manuscript
Author Manuscript

Figure 4.
Match injury incidence forest plot with 95% CIs. AMC, American tournament; CC,
confederation tournaments; CWC, clubs world tournaments; EC, Europe tournament; nt,
national team; OG, Olympic games; U, under; WC, world tournament.
Author Manuscript

Br J Sports Med. Author manuscript; available in PMC 2023 February 15.

 López-Valenciano et al. Page 23
Author Manuscript
Author Manuscript

Figure 5.
Injury incidence rates (with 95% CIs) by location of lower extremity injuries.
Author Manuscript
Author Manuscript

Br J Sports Med. Author manuscript; available in PMC 2023 February 15.

 López-Valenciano et al. Page 24
Author Manuscript
Author Manuscript

Figure 6.
Injury incidence (with 95% CIs) by type of injury.
Author Manuscript
Author Manuscript

Br J Sports Med. Author manuscript; available in PMC 2023 February 15.