Football Player Injuries - Are they becoming more frequent?

Football injuries - are they really on the rise?

With the World Cup in full swing, the media has been full of stories about the apparently increasing incidence of injuries among professional footballers. But as TJ Salih explains, the reality is far more complicated than the tabloid headlines would have you believe

Football is a highly athletic sport with rapid deceleration, acceleration, single-stance twists, single-stance ballistic movements and aerobatic manoeuvres. This may explain why the overall level of injury to a professional footballer has been shown to be around 1,000 times higher than in industrial occupations generally regarded as high risk (1).

During the run up to the World Cup, few can have been unaware of the increased reporting of injuries to high profile footballers. Just 10 days before the start of the tournament, the sporting headlines were full of footballing injury stories. The Argentina and Barcelona forward Lionel Messi was still recovering from a thigh injury, while his fellow countryman and Villarreal centre back Gonzalo Rodríguez had effectively waved goodbye to his chances of going to the World Cup Finals after tearing a ligament in his left ankle. Meanwhile, the Germany and Bayern Munich player, Michael Ballack, was also doubtful due to an ankle injury, as was the Dutchman Rafael van der Vaart of Hamburg, who limped out of training after hurting the same ankle he thought had healed. And with the British media brimming with stories about the fitness or otherwise of Michael Owen and Wayne Rooney, it’s been hard to avoid the conclusion that the overall incidence of footballing injuries is increasing.

However, there’s mixed evidence for this. Increased sport participation does increase the risk(2), but on an hour-for-hour participation basis, it is likely that the risk has remained the same (3). The fact that certain injuries can keep high profile players away from the game for months or even years brings particular injuries into the public arena. With this in mind, this article reviews the evidence for injury patterns to the lower limb and spine, the mechanisms of injury, and the trends and possible theories underlying the findings.

Lower limb injuries

With the advent of Wayne Rooney’s injury in the run-up to the World Cup, metatarsal fractures have been topical. Rooney fractured the fourth metatarsal in his right foot. This type of injury has also afflicted other international players, such as Edwin van der Sar (Netherlands and Manchester United), Gaël Clichy (France and Arsenal), Ivan Campo (Spain and Bolton) and Paulo Ferreira (Portugal and Chelsea).

The high incidence of metatarsal fractures in football players has raised the question as to whether modern football boots offer enough protection to the foot and whether they are to blame for the high number of foot injuries. Indeed, Rooney was wearing a new Nike model, the Total 90 Supremacy, for the first time on the day that he was injured.

Although Nike denies that its boots are linked to a higher risk of injury, Tommy Docherty, the former manager of Manchester United, said that when he was a professional football player in the 1950s, it used to take six weeks to break a pair of boots in and players used to have to put them in a bucket of water (4)!

The English Football Association also states that, ‘players are ill-advised to start a game having not previously worn the boots they are to play in as it may lead to unnecessary injury’. They also go on to advise how to break in the boots progressively during training sessions prior to wearing them in a match, and concur with the idea that soaking them in water may not be a bad idea(5). The theory here is that the water softens the leather and allows the boot to be broken in faster.

Another reason why we are hearing more of these types of injury is the terminology now used and the increased reporting of the injury by the media. Tony Book, a former professional UK footballer, told the Manchester Evening News that he believes the name of the injury has changed. He believes the old ‘broken toe’ injury is now reported as ‘fractured/broken metatarsal’ (4). This changing terminology, coupled with increased media reporting, may be giving rise to a perceived increase in the number of injuries. There may not be more metatarsal injuries now than there used to be, but we all certainly know more about them (6).

Before MRI scans were widely available, ‘ankle pain’ was common, but now we have various degrees of ‘bone bruises’. Likewise, in 1960, no one had heard of ‘Gilmore’s Groin’, but by 1990 everyone had one! Again, this indicates that with changing times and advances in technology, the terminology changes but the underlying injury does not.

The foot and footwear

When considering the foot in the context of injury, we have to allow for the position of the foot on the ground, the forces applied to it and the type of grip available (in terms of studs or blades) and any additional support offered by the footwear.
Other forces may come into play with the other foot (the non-stance foot), and relate to the instantaneous forces applied to the toes, foot and ankle in kicking the ball, or accidentally kicking or being kicked by another player.

Ideally any boot should:
1. provide good grip and traction to allow rapid acceleration/deceleration and change of direction;
2. provide adequate support and stability for the foot;
3. distribute the load and decrease the shock of impact;
4. protect the foot and toes against direct trauma (ball and another boot);
5. be comfortable and flexible (7).

The older style football boot with its hard toecap and high sides offered protection to the foot and ankle, but limited the range of motion of both (8). The design of modern football boots allows the foot and ankle total freedom of movement to provide maximum flexibility to the player. But has the modern football boot succeeded in protecting the player while optimising performance? Also, have the changes led to injuries elsewhere, such as an increased tendency to rupture the anterior cruciate ligament, by virtue of increasing torsion on the extended knee?

The available research on these questions is far from conclusive, as the literature is full of anecdotal and conflicting evidence. Simply looking at the number of injuries to the foot is of little value since the forces on the foot cannot be accurately assessed and the level of play, position on pitch and technique would have to be taken into consideration.

It is very easy to blame football players’ ‘tools’, but other factors also have to be taken into account and it is highly unlikely that any single factor is to blame for an injury pattern. It is also unlikely that any single factor could be isolated unless there was a large increase in a particular type of injury in association with a particular boot or playing surface.

What the research says

Research has identified three main factors that influence the increased likelihood of injuries in football players:

  • Intrinsic factors, such as age, previous injury history, fitness and skill level;
  • Extrinsic factors such as the amount and quality of training, playing field conditions, equipment (eg boots, shin guards), subjective exercise overload during training and matches;
  • Violation of the rules (foul play) (9).

For example, artificial playing surfaces have been implicated in non-contact injuries of the lower limb, such as ruptures of the anterior cruciate ligament. Evidence from research in America has indicated that there may be an increased number of lower limb injuries when playing on artificial surfaces compared with grass (9, 10). Again, however, we cannot simply blame artificial grass, as it appears that variations in shoe-surface traction can also account for some injuries(11). This includes ground hardness, dryness, grass cover, grass root density, length of studs on players’ boots and relative speed of the game. It is possible that measures to reduce shoe-surface traction, such as ground watering and softening, and players using boots with shorter studs, may reduce the risk of football injuries (12).

Studies have indicated that up to 87% of injuries in football occur in the lower limb (thigh, knee and ankle), with only 38% of injuries involving player-to-player contact (13). With this in mind, non-contact injury mechanisms are under increasing analysis in order to try to minimise and reduce further injuries.

Spinal pain and football

Modern football requires exceptional gymnastic abilities in the spine as well as the lower limbs. The spine, in conjunction with the ‘grounded’ foot, provides the stable platform for the mobile foot to kick the ball, or for the head to head the ball.

The spine is a complicated system of segmented levers with 33 joints stacked one on top of each other, separated by small shock absorbers. It is therefore no wonder that it occasionally fails. As people age, so do the intervertebral discs, and this process can start as early as the mid-20s. Players are therefore at increased risk of injury to their spine during the peak of their career but this is likely to be a feature of degeneration and heavy demand rather than one of increased rate of injury because of a single occupational aspect of sport.

Considering the number of lower limb injuries sustained by football players, it is surprising that more do not get spinal pain. One possible explanation could be that the selection process for footballers is such that those with back pain develop symptoms early in their career and never reach the status of an elite athlete.

Another explanation is that spinal flexibility, spinal muscle strength and highly developed motor pathways protect the players from the potential damage to the spine that might result in pain. Indeed, severe back pain is uncommon in footballers and injury patterns such a spondylolisthesis (as often seen in cricket players) is absent. One noteworthy exception to this is David Beckham who suffers from back pain. He has been reported to have one leg (left) shorter than the other; this, together with his unique kicking style, may put unusual stress on certain areas of his spine and therefore cause his particular pain and dysfunction.

Seasonality and overuse injuries

Footballers generally only have four to six weeks off from training and playing. If they are not involved in cup games or representing their country, they may stop playing in mid-May and restart pre-season training in July. However, if they are playing for their country in tournaments (such as the World Cup) most players will be lucky if they have three to four weeks of not playing football. With this amount of time spent playing, overuse injuries are not uncommon.

Overuse injuries are unlikely to be a significant influence in overall injury trends. The risk of injury is related to the time spent playing (just as the risk of a driver crashing a car is related to the number of miles travelled). Below a certain minimum playing time, the risk is increased where there is a lack of skill or training or there is poor fitness, but above this level, increased play, on balance of probabilities, will result in increased injuries.

Although this makes sense, research has found that top level football players who also represented their country in a World Cup (and so played more games than players who did not play for their country) did not show any increased risk of injury during the season, and actually had a lower injury risk at training than non-World Cup players (14).

Pre-season injuries in football are inevitable, possibly due to a number of factors, such as a decrease in fitness, hard playing surfaces (after the summer), fatigue or inappropriate content or progression of pre-season training programmes. One study found that 17% of all injuries occurred during pre-season training, with the average time lost from these injuries being 22 days. It was also found that younger age groups (17-25 years old) sustained more pre-season injuries that senior players (26-35+ years old) (15). Overall, however, injury in youth team (academy) football is approximately half that of professional players (16).

What can we learn?

In this modern era, with increased coverage of football on television, media demand and financial influence, we all want to know how and why our favourite football players are getting injured, and when they will be able to play again. For the fans, this is an important question; for the club and player it is a vital question. With the cost to professional clubs in England of injuries occurring during an average season estimated to be in excess of £75m and up to 10% of the professional squad unable to play due to injury, it is imperative that measures to prevent injuries, and not just to treat them, are in place.
Studies have shown that better shin pad design may help cut the rate of tibial fractures (sometimes known as ‘footballers fracture’) (17). However, this particular study also showed that 85% of footballers wearing shin pads still sustained a tibial fracture, suggesting there’s a long way to go.
Other simple measures may prevent some of these injuries. These include:

  • a joint approach to training between the medical and coaching staff;
  • a progressive training regime during the pre-season;
  • wearing running trainers or shock absorbent orthotics when the ground is hard in pre-season;
  • using other training methods to get players’ cardiovascular fitness up prior to running, eg cycling.

Injuries also occur at the amateur level. There are essential differences between the amateur and professional footballer (apart from the salaries!) and this revolves around training and pre-game preparation. The lessons that have been learned in professional football should be used in the amateur game in an attempt to reduce injuries. Likewise, the lessons from other sports should be used to help professional footballers improve their game and prevent them from becoming injured.

TJ Salih is a chartered physiotherapist and worked for Tottenham Hotspur Football Club for two seasons, before establishing his own clinic, Back2Normal –

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2) Acta Orthop Scand 1976 Feb; 47(1):118-21
3) Am J Sports Med 2004; 32(1 Suppl):23S-7S
4) Medical News Today, 2nd May 2006
5) The; 24 June 2003; ‘Close Season Encounters’
6) BBC Sport; Health & Fitness; ‘Metatarsals – a football fad?’
7) The; 17th March 2004; ‘Putting the boot in’
8); Feb 2000; ‘Taping Ankles: Prevention or Cure?’
9) Am J Sports Med 2000; 28:S (2000)
10) Am J Sports Med 1992; 20(6):686-94
11) Am J Sports Med 2006; 34(3):415-22
12) Sports med 2002; 32(7):419-32
13) Br J Sports Med 2001; 35;43-47
14) Br J Sports Med 2004; 38:493-497
15) Br J Sports Med 2003; 36:436-441
16) Br J Sports Med 2004; 38;466-471
17) Br J Sports Med 1996; 30;171-175

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