Abstract
Football, or soccer, as it is called in North America, is the most popular sport worldwide. There are currently about 200 million players, 40 million of whom are women. The ever-increasing number of active players, leading in turn to an increasing frequency of injury with resultant cost for treatment and loss of playing time, makes evident the need for an injury prevention program. The Fédération Internationale de Football Association (FIFA), as the governing body of football, realized the need and decided to play an active role in developing and supporting research on football. However, to develop such a program requires epidemiologic data and analyses of risk factors. The currently available data concerning risk factors and predictors for football injury are inconsistent and far from complete. Thus, we proceeded to conduct a football study with the main aims of:
examining the physical performance and psychosocial characteristics of football players in different age groups, playing levels, and sociocultural environments;
evaluating the incidence of football-related injuries and complaints;
analyzing the influence of factors such as physical performance, medical history, and pathologic findings, as well as the influence of psychosocial characteristics, on the frequency and severity of injury;
developing, based on the analysis of risk factors and predictors, a program of optimal training to reduce the incidence of injury and somatic symptoms.
Five hundred eighty-eight players from Germany, France, and the Czech Republic were followed weekly over the course of 1 year by unbiased physicians. Our study design involved simple methods of assessment so that we could apply these methods even in the less-developed countries on the different continents. We developed new definitions of injuries to account not only for absence from training and games, but also for medical treatments and related rehabilitation. The assessment of the players at the beginning of the study included medical examination by specially trained orthopaedic physicians, followed by assessment and evaluation of football skills and performance.
Our results led to some remarkable findings. By comparing weekly follow-up notes from our physicians with retrospective questionnaires covering the same observation period, it was found that after 1 year more than half of all injuries, including severe ones, had been forgotten or neglected. Hence, retrospective assessment of soccer injuries and related complaints are of limited value. Weekly follow-up notes also revealed the incidence of injury to be 2.1 per player per year. After separate calculation of training and playing (game) hours and then calculation of total exposure, we found there were 4.3 injuries per 1000 training hours, 20.3 injuries per 1000 game hours, and 7.3 injuries per 1000 hours of total exposure. Twenty-seven percent of all injuries were the result of fouls. Additionally, almost all players (92%) were ready to commit intentional, or “professional,” fouls if required, depending on the score and the importance of the match. Twenty-three percent of all injuries were due to overuse. It was also found that low-skill level players or teams incurred almost twice as many injuries as did high-skill level players. This was perhaps due to the quality of training as well as to fewer training hours per game.
Based on our results, presented in this supplement, and our analysis of multidimensional predictors, we recommend a prevention program. Such a program must include not only the players, but also the trainers and the responsible physicians and physical therapists. The most important interventions to reduce the injury rate are as follows:
From the trainers’ perspective: structured training sessions, appropriate warm-up, appropriate game/training relationship, reduction of playing time.
From the medical perspective: adequate rehabilitation, sufficient recovery time, attention to all complaints, taping of ankle joints.
From the players’ perspective: improvement of performance (flexibility, skills, endurance), improvement of reaction time, good lifestyle habits (avoidance of smoking and alcohol, balanced nutrition), and, of course, appropriate attitude toward fair play.
From the referees’ perspective: reduction of foul play with appropriate interpretation and implementation of the existing rules.
It remains for future prospective studies to prove that such prevention recommendations will lead to a reduction of injury incidence as well as the players’ symptoms related to football.
The Fédération Internationale de Football Association, the world governing body of football, which currently unifies 204 national associations, has realized that it is their responsibility to guarantee a smooth government of the different competitions in the spirit of fair play in all age groups and levels of play and for both sexes. Thus, FIFA is also aware of its responsibility for the health of its football players. The increasing number of games being played annually at all levels is obviously accompanied by a higher incidence of injuries and physical symptoms. It is the aim of FIFA to ensure, based on the current body of knowledge, that the increasing incidence of injury is reduced and that acute injuries as well as secondary degenerative changes are prevented. Those fundamental considerations were the basis for the present studies being substantially supported by the FIFA governing body and its new management. The authors of the studies presented here, some of whom are members of the FIFA Medical Assessment and Research Center (F-MARC), Zurich, Switzerland, would like to acknowledge the support of these studies by FIFA, particularly the former president, Mr. Joao Havelange and the current president, Mr. Joseph S. Blatter, as well as the Chairman of the Sports Medical Committee, Dr. Michel D'Hooghe. They also express their thanks to all the football teams who participated in the studies.
We hope that the results and conclusions presented in this supplement issue will stimulate a dialogue among involved professionals and researchers that will lead to the design of an appropriate prevention program. The players and the game itself stand to benefit from a reduced injury rate as well as related complaints.