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00/0
THE AMERICAN JOURNAL OF SPORTS MEDICINE, Vol. 28, No. 5
© 2000 American Orthopaedic Society for Sports Medicine
Football Injuries and Physical Symptoms
A Review of the Literature
From the Schulthess Clinic, Zurich, Switzerland
ABSTRACT
Football is one of the most popular sports worldwide.
The frequency of football injuries is estimated to be
approximately 10 to 35 per 1000 playing hours. The
majority of injuries occur in the lower extremities,
mainly in the knees and ankles; the number of head
injuries is probably underestimated. The average cost
for medical treatment per football injury is estimated to
be $150 (U.S. dollars). Considering the number of
active football players worldwide, the socioeconomic
and financial consequences of injury are of such a
proportion that a prevention program to reduce the
incidence of injuries is urgently required. For this rea-
son, an analysis of intrinsic (person-related) and ex-
trinsic (environment-related) risk factors was under-
taken based on a review of the current literature. It was
concluded that the epidemiologic information regarding
the sports medicine aspects of football injuries is in-
consistent and far from complete because of the em-
ployment of heterogeneous methods, various defini-
tions of injury, and different characteristics of the
assessed teams. The aim of this study was to analyze
the literature on the incidence of injuries and symptoms
in football players, as well as to identify risk factors for
injury and to demonstrate possibilities for injury
prevention.
Football is one of the most popular sports worldwide, with
an increasing number of active players as well as specta-
tors. Currently, FIFA, the world governing body of foot-
ball, unifies 203 national associations and represents
about 200 million active players, of which about 40 million
are women.
Based on well-established epidemiologic studies, the in-
cidence of football injuries in adult male players is esti-
* Address correspondence and reprint requests to Jiri Dvorak, MD, Spine
Unit, Schulthess Clinic, Lengghalde 2, CH-8008 Zurich, Switzerland.
No author or related institution has received any financial benefit from the
research in this study.
S-3
Jiri Dvorak,* MD, and Astrid Junge, PhD
mated to be 10 to 35 per 1000 game hours (see Table 1).
Assuming one athlete plays on average 100 hours of foot-
ball per year (about 50 hours per player for a local team,
up to 500 hours per player for a professional team), it is
estimated that every player will incur at least one perfor-
mance-limiting injury per year. In view of the increasing
frequency of injury, the resulting primary and secondary
costs, and, not least, the personal suffering of the injured
players, analyses of risk factors are required as an essen-
tial prerequisite to the development of prevention pro-
grams. An excellent review of epidemiologic studies by
Inklaar28, 29 pointed out that the current information con-
cerning risk factors and predictors of football injuries is
inconsistent and far from complete.
DEFINITION OF INJURY IN FOOTBALL
No consensus regarding the definition of injury in football
has yet been reached.28, 33, 47 In most studies concerning
the incidence of football injuries, different criteria have
been used. This makes the direct comparison and inter-
pretation of results difficult and at the same time is a
possible explanation for the somewhat differing results.
The most common criterion in the definition of an injury
is an absence from training or game(s) followed by the
need for medical treatment and the diagnosis of anatomic
tissue damage. This criterion, however, can be misleading
and is open to misinterpretation. Absence from training
and games is not only influenced by a very strong subjec-
tive component but is also directly affected by the fre-
quency of games, the availability of medical treatment
and, finally, factors such as the importance of the player
and the expected outcome of the game.33 In some studies,
football injuries are recorded based on insurance company
records, which implies that the injured player was treated
by a physician or in a hospital.49, 54 This system probably
leads to an underestimation of the incidence of less severe
injuries or symptoms due to overuse, which are not always
subject to medical treatment. The medical diagnosis may
seem to be an objective criterion, but it is also directly
related to the availability of qualified physicians. The
Council of Europe defined a football injury as an injury
S-4 Dvorak and Junge American Journal of Sports Medicine

occurring as the result of participation in official football activ-
ities with one or more of the following consequences: reduction
in the amount of football activity, need for advice regarding
treatment, and adverse social or economic effects.69
Closely related to the pitfalls and biases in the definition of
injury is the rational estimation of the degree of severity.
Van Mechelen et al.68 suggested six criteria to account for
the degree of injury severity: type of injury, duration and
modality of treatment, absence from training and playing,
work disability, structural changes and irreversible damage
to the body, and costs related to the injury treatment.
Some of these criteria are described in epidemiologic
studies.28 However, the degree of severity is almost al-
ways related to the duration of absence from training and
participation in games. If absence from training and
games is used as the criterion to indicate the degree of
injury severity, it must be noted that absence may also be
influenced by other factors, including psychological ones.
It is not, therefore, an absolutely objective measure.
INCIDENCE OF INJURY IN FOOTBALL
Injury incidence is defined as the number of injuries oc-
curring during a study period. Consequently, the inci-
dence of football injuries has most frequently been calcu-
lated based on the time period when there was a risk of
injury, that is, the hours during games and training. In
some studies, the incidence has been calculated per 1000
hours of football without specification as to whether these
1000 hours were only competitive games or whether they
also included training time.28, 33 In other studies, the in-
cidence has been calculated for 1000 hours of games as
well as for 1000 hours of training, but in each case using
the total number of injuries. When analyzing the risk
factors leading to an injury, most researchers do not
present the important differentiation between injuries oc-
curring during games or during training. There are not
only methodological difficulties in calculating the inci-
dence of injury, but also other influencing factors, such as
age, sex, and the level of play, that have to be taken into
account to compare the different studies.
The overall analysis of injury rates in the different
studies results in an incidence ranging from 0.5 to 45
injuries per 1000 hours of practice and games.28 The in-
cidence of injuries varies in different studies because of
differences in research design and characteristics of the
population. In adult male players, the incidence is about
12 to 35 injuries per 1000 hours of outdoor games and 1.5
to 7.6 injuries per 1000 hours of practice (Table 1). In
female players and adolescents, the incidence of injury
seems to be lower. In indoor football players, the incidence
of injury seems to be higher.28 Table 1 provides an over-
view regarding the incidence of injuries in male outdoor
football players based on relevant epidemiologic studies.

TABLE 1
Epidemiologic Studies on the Incidence of Injury in Male Outdoor Football Players

No. of Injuries per 1000 hours (mean ⫾ SD)

Authors Population (age) Study period
players Games Practice Exposure

Hawkins and Fuller 23 108 Professional players 3 seasons 25.9 3.4

30 Youth players 3 seasons 37.2 4.1
Lüthje et al.38 263 Elite players (17–35 years) Season 16.6 1.5
Inklaar et al.30 75 Adolescents (13–14 years) Season 12.8
78 Adolescents (15–16 years) Season 16.1
79 Adolescents (17–18 years) Season 28.3
245 Adolescents (⬎18 years) Season 15.8
Arnason et al.3 84 Elite players (18–34 years) Season 34.8 ⫾ 5.7 5.9 ⫾ 1.1
de Loës12 350,000 “Young people” (14–20 years) 1987–1989 0.7
Kibler34 Adolescents (12–19 years) Tournament 2.4
Blaser and Aeschlimann10 90 Division leagues (16–42 Tournament 2.1 to 10.7
years) (different
leagues)
Schmidt-Olsen et al.56 496 Adolescents (12–18 years) 1 year 3.7
Poulsen et al.48 19 Division 1 1 year 19.8 4.1
36 Series 3 & 5 20.7 5.7
Yde and Nielsen71 152 Adolescents (6–18 years) Season 5.6
Engström et al.21 64 Elite players 1 season 13 3
Ekstrand and Tropp20 639 Senior players (17–38 years) 1 year
135 Division 1 21.8 ⫾ 1.7 4.6 ⫾ 1.7
180 Division 2 18.7 ⫾ 1.7 5.1 ⫾ 1.7
(Ekstrand et al.18) 180 Division 4 (1980) 16.9 ⫾ 2.1 7.6 ⫾ 2.1
144 Division 6 14.6 ⫾ 5.9 7.5 ⫾ 5.9
Nielsen and Yde44 34 Division level Season 18.5 2.3
59 Series level 11.9 5.6
30 Youth (⬎16 years) 14.4 3.6
Backous et al.4 681 Adolescents (6–17 years) Summer camp 7.3
Hoff and Martin26 455 Adolescents (⬍8–16 years) Competition 7.4
Maehlum et al.39 1016 Adolescents (⬍12–18 years) Norway Cup 9.9
Schmidt-Olsen et al.55 5275 Adolescents (9–17 years) Tournament 16.1
Sullivan et al.58 931 Adolescents (7–18 years) Season 0.5
Nilsson and Roaas46 25,000 Adolescents (11–18 years) Tournament 14
Vol. 28, No. 5, 2000
LOCATION AND NATURE OF INJURIES
Football injuries affect mostly the ankle and knee joints,
as well as the muscles and ligaments of the thigh and
calf.22, 28, 66 Inklaar28 concluded from his review of the
literature that 61% to 90% of all injuries occurred in the
lower extremities. Goalkeepers, however, have more head,
face, neck, and upper extremity injuries than lower ex-
tremity injuries.6 Inklaar et al.30 found that the distribu-
tion of injuries according to body part seemed unrelated to
age-group distribution. However, more upper leg injuries
were sustained at a high level of play than at lower levels.
The most common types of injuries in football are con-
tusions, sprains, and strains. Youth players sustain more
contusions and fewer overuse injuries than do senior play-
ers. A higher percentage of strains has been registered in
professional football than in senior amateur football.28
Most football injuries are traumatic, and the proportion
of injuries caused by overuse varies from 9%3 to 34%.44
Inklaar et al.30 reported that the distribution of traumatic
and overuse injuries was not related to age-group distri-
bution. However, in the senior age group more overuse
injuries were sustained at a high level than at a low level
of play.
Head injuries have been shown to account for 4% to 22%
of all football injuries.67 The effect of concussions and head
injuries on neuropsychological impairment has been in-
vestigated by several authors.5, 11, 31, 40, 41, 57 Jordan et
al.31 designed a study to determine whether chronic en-
cephalopathy occurred in elite active football players as a
result of repetitive heading of the football. A group of 20
football players was compared with 20 age-matched elite
male track athletes. A battery of neuropsychological tests
was used to assess cognitive function, and MRI scans were
also performed. Both the questionnaire analyses and MRI
demonstrated no statistically significant differences be-
tween the two groups.
In a more recent study by Barnes et al.,5 137 young male
and female football players were evaluated. There were 74
cases of concussion registered in 39 male players and 28
cases in 23 female players. For the men, 48 (65%) episodes
resulted from collision with another player. Headaches,
dizziness, and being “dazed” were the most common symp-
toms reported. The authors concluded that concussion re-
sulting from player-to-player contact was a frequent haz-
ard in football. Head injuries incurred this way may exert
more of an influence on the published findings of physio-
logic and psychological deficiencies than routine heading
of the ball. The same research group analyzed 29 cases of
concussion diagnosed over 2 years in 26 athletes.11 In the
majority of the cases (69%), concussion occurred during
games. Several injury mechanisms were identified, the
most common scenario being a collision with another play-
er’s head (28%) or elbow (14%). Seven players (24%) were
hit in the head by balls kicked with full force at a range so
close that the players were unable to react quickly enough
to protect themselves. However, none of the concussions
resulted from intentional heading of the ball. The basic
incidence of concussion was 0.96 cases per team per sea-
son. Boden et al.11 concluded that concussion is more
Football Injuries and Physical Symptoms S-5
common in football than previously thought and that
acute head injuries may be the potential cause of long-
term neuropsychological changes.
Matser et al.40, 41 investigated chronic traumatic brain
injury in professional and amateur football players. Fifty-
three active professional football players from several pro-
fessional Dutch football clubs and 33 amateur players
from 3 regional league clubs were compared with a control
group of 27 elite athletes from noncontact sports. All par-
ticipants underwent neuropsychological tests proven to be
sensitive to cognitive changes incurred during contact and
collision sports. The professional as well as the amateur
football players exhibited impaired performance in mem-
ory and planning (professional players had additional im-
pairment in visuo-perceptual processing) when compared
with control subjects. Performance on these tests was
inversely related to the number of concussions incurred in
football40, 41 and to the frequency of heading the ball.41
Among professional players, performance on the neuro-
psychological testing also varied according to field posi-
tion, with forwards and defensive players exhibiting more
impairment.41 The authors concluded that participation
in professional and amateur football may adversely affect
the aforementioned aspects of cognitive functioning.40, 41
There are only a few studies concerning football-related
symptoms and secondary degenerative structural changes
in former football players. Räty et al.50 studied the life-
time occurrence of musculoskeletal problems in former
elite male athletes and found that former football players
had more back pain and knee pain than former long-
distance runners or shooters. Roos et al.53 reported that
the prevalence of gonarthrosis was 15.5% among elite
former football players, 4.2% among nonelite players, and
1.6% among age-matched controls. The authors concluded
that football, especially at an advanced level, is associated
with an increased risk for gonarthrosis.
Comparing 57 retired football players with a control
group of men of the same average age and weight, Klünder
et al.35 found osteoarthritis of the hip joint more often in
the football players (49.1%) than in the control group
(26.3%). Lindberg et al.37 compared the occurrence of cox-
arthrosis in 286 former football players with that in an
age-matched control group (mean age, 55 years). Hip cox-
arthrosis occurred in 5.6% of the former football players
and in 2.8% of the control group. Among 71 elite football
players, the prevalence of coxarthrosis was 14%, com-
pared with 4.2% in the age-matched control and nonelite
players.37
Roos52 concluded from his review of the literature on
long-term sequelae from football that a long-term football
career seems to increase the risk for early development of
osteoarthritis in the lower extremity. This risk was higher
in top-level players. Football constitutes a risk for osteo-
arthritis in two different ways. First, there is the in-
creased risk for knee injuries in football, such as meniscal
and ACL injuries; second, there is the factor of the exces-
sive repetitive loading on the hip and knee joints that
occurs in football. In elite football players, knee and ankle
injuries seem to lead to a serious long-term outcome, but
S-6 Dvorak and Junge
uninjured players also have a higher risk of developing
arthritis than the normal population.36
ESTIMATED COSTS OF INJURIES AND POSSIBLE
COST REDUCTION
In 1981, Pritchett49 collected insurance company data re-
lated to injuries of high school football players. The aver-
age claim cost was $127 (U.S. dollars) for injuries in 1976
and 1977. Relatively minor injuries, such as sprains,
strains, and abrasions, accounted for 76% of all injuries
but only 49% of all costs. Lower extremity injuries ac-
counted for more than one-half of all injuries and costs.
De Loes13 analyzed 571 injuries occurring in 28 differ-
ent sports. The overall average cost per injury was $335
(U.S. dollars). Individual sports such as motorcycling and
downhill skiing were by far the most costly. The most
expensive of the team sports, ranking only fifth, was hand-
ball, followed by football. The average individual cost of
the 241 football injuries assessed was calculated as being
$188 (U.S. dollars) (SD, $313).
Ekstrand et al.17 showed that an injury reduction rate
of 50% to 70% might be possible if prevention programs
were implemented. The effect of such a reduction would be
considerable in view of the enormous medical costs and
the secondary costs involved (loss of playing or working
days). Inklaar28 concluded from his review that, on aver-
age, a football player suffers one injury per year. A con-
servative estimate of the average primary medical costs
associated with one football injury is $150 U.S. dollars.
There are approximately 200 million active players regis-
tered with FIFA; simple multiplication indicates that the
primary medical costs associated with football injuries is
$30 billion U.S. dollars per year. There are no reliable
prospective epidemiologic studies, but this estimate can
probably be considered realistic, although it does not in-
clude the costs associated with the loss of competition or
working days. Of course, this estimate remains hypothet-
ical as the costs of medical treatment differ in different
countries and are probably much lower in countries where
medical services are not as well developed as they are in
the countries where the studies have been performed.
CAUSES OF FOOTBALL INJURIES
In general, a distinction has been made between so-called
intrinsic (person-related) and extrinsic (environment-re-
lated) risk factors.28, 60, 68 The intrinsic risk factors are
related to the individual biological or psychosocial charac-
teristics of a person, such as age, joint instability, muscle
strength, muscle tightness, muscle strength asymmetry,
previous injuries, adequacy of rehabilitation, and psycho-
social stress. Extrinsic risk factors relate to environmen-
tal variables such as the level of play; exercise load
(amount of competition and practice); amount and stan-
dard of training; position played; equipment such as shin
guards, taping, and shoes; playing field conditions; rules;
and foul play. Both intrinsic and extrinsic factors can
partially influence each other and are therefore not inde-
pendent of each other. Age can also be a factor in the cause
American Journal of Sports Medicine
of football injury. Most authors have found that the inci-
dence of injury increases with age.4, 26, 27, 29, 42, 43, 56
Joint Instability
Both mechanical and functional instability predispose
athletes to sprains of the knee and ankle.29 Arnason et al.3
found that significantly more injuries occurred in knees
with medial instability than in stable knees. Ekstrand and
Gillquist15 reported that three players who had anterolat-
eral rotatory instability (positive pivot shift sign) detected
on examination sustained a knee injury in the following
year and had to give up football permanently.
Ankle sprains have also been shown to occur more fre-
quently in players with clinical instability.15 Players with
abnormal stabilometric values run a significantly higher
risk of sustaining an ankle injury during the following
season than do players with normal values.64 Only Arna-
son et al.3 found no difference in the number of ankle
sprains between ankles with lateral or anterior instability
and those that were stable.
Muscle Strength, Tightness, and Asymmetry
Ekstrand and Gillquist15 reported that players who sus-
tained knee sprains that were not due to collision had
reduced muscle strength in the injured leg. No other
strength differences between injured and uninjured play-
ers were found in this study. Inklaar29 has found a corre-
lation between tight muscles and strains of the adductor
muscles. Significantly more players with muscle tightness
(N ⫽ 34) sustained a muscle rupture or tendinitis than did
those with normal flexibility (N ⫽ 10). The 13 players who
had rupture of the adductor muscles or tendinitis showed
significantly lower ranges of motion in hip abduction. No
significant influence of range of motion was found with
regard to hamstring muscle strains or knee and ankle
sprains.15
Muscle asymmetry seems to contribute to the risk of
injury in football players. Agre and Baxter1 reported that
one player with a side-to-side difference in hip abduction
of 9° and three of four players who had side-to-side differ-
ences in hip flexion of 6° or greater were subsequently
injured. Ekstrand and Gillquist15 found that the strength
quotient for the injured/uninjured legs of players with
noncontact injuries was significantly lower than the right/
left quotient in uninjured players.
Body Mechanics
Watson70 investigated possible relationships between the
incidence of injuries and the existence of defects in “body
mechanics” in players of various types of football. Injuries
were recorded prospectively over a 2-year period. A stan-
dardized set of examinations employing photogrammetric
techniques was used to assess 52 subjects. It was found
that football players who suffered from ankle injuries had
lower scores for ankle mechanics than did uninjured play-
ers. Knee injuries were found to be associated with a
higher degree of lumbar lordosis and the presence of sway
Vol. 28, No. 5, 2000
back. Subjects who suffered from muscle strains had a
higher incidence of lumbar lordosis, sway back, and ab-
normal knee interspace. Back injuries were associated
with poor shoulder symmetry, scapular abduction, back
asymmetry, kyphosis, lordosis, and scoliosis. In general,
Watson found that the incidence of ankle, back, knee, and
muscle injuries was influenced by the presence of a defect
of body biomechanics. These results suggest that interven-
tion programs to improve body mechanics might help re-
duce the incidence of sports injuries in football players.
Psychological Factors
Several empirical studies have demonstrated the influ-
ence of psychological factors on sports injuries.2, 32, 60 How-
ever, only one article addresses this issue particularly in
relation to football.61 Although these studies are difficult
to compare because of the different methods employed, the
results generally agree that life-event stress increases the
risk of a sports injury.32 From the numerous psychological
attributes that have been investigated in relation to sports
injuries, only competitive anxiety has demonstrated any
association with injury. A typical personality profile of an
athlete likely to be injured does not exist. However, some
studies have shown that injured athletes demonstrate a
lack of caution and an adventurous spirit. It appears that
mental performance has been largely neglected in the
past, although Taimela et al.61 showed that a prolonged
reaction time was an important predictor of injury in
football.
Previous Injury and Inadequate Rehabilitation
Previous injuries and inadequate rehabilitation are the
most important and well-established intrinsic risk factors
for future injury.3, 14 –16, 20, 44 Nielsen and Yde44 reported
that in 42% of injured players there had been an injury of
the same type and location during the previous year. In
elite Belgian football players, 30% of sprains and strains
were reinjuries of the same type and location.29 Arnason
et al.3 stated that the frequency of reinjury was high
(35%), with 44% of muscle strains and 58% of ligament
sprains being registered as reinjuries of the same type and
at the same location.
Ankle sprains have been shown to be more common in
players with previous ankle sprains.15 Arnason et al.3
found that 9 of 13 ankle sprains (69%) in their study were
in players with a history of previous sprain. Nielsen and
Yde44 reported that all players who sprained an ankle
while running had a previous history of ankle sprain.
Ekstrand and Tropp20 calculated a 2.3 higher risk of ankle
sprain in players who had previously sustained ankle
sprain. Only Tropp et al.64 reported that players with a
previous ankle joint injury did not have a higher risk of
future injury compared with players with no previous
injury. Their stabilometric recordings of 25 football play-
ers showed that an ankle joint injury did not result in
persistent functional instability65; nonetheless, such in-
stability, per se, did increase the risk of future ankle joint
injury.64
Football Injuries and Physical Symptoms S-7
The relatively high percentage of reinjury in football
suggests inadequate rehabilitation and incomplete heal-
ing as a risk factor.29 Nielsen and Yde44 found that in 59%
of reinjuries the players had not completely recovered
from a previous injury. Ekstrand and Gillquist15 reported
that players who sustained moderately serious or major
noncontact knee sprains had usually suffered a previous
knee sprain with subsequent persistent mechanical insta-
bility. Overall, they attributed 17% of all injuries to inad-
equate rehabilitation of the previous injury. The analysis
of injury sequences revealed that minor injuries were of-
ten followed by a major injury.15, 16 One-third of the mod-
erate or severe injuries occurred within 2 months after a
minor injury.16
Level of Play and Position on the Field
Studies regarding injuries associated with different skill
levels have produced contradictory results. Inklaar et al.30
reported a higher injury incidence for higher levels of play
in four different age groups. Nielsen and Yde44 found the
injury rate during games was highest at the division level
and lowest at the series level, whereas during practice, the
outcome was the reverse. The same distribution was ob-
served in the group investigated by Ekstrand and Tropp,20
but the authors stated that the total incidence of injury
was the same across differing levels of skill. Bjordal et al.9
showed that the rate of ACL injuries gradually decreases
at lower levels. Blaser and Aeschlimann10 reported that
the highest frequency of injury was seen in the lower
leagues. Poulsen et al.48 found no difference in the injury
rate per 1000 hours of practice or games between high-
and low-level football players.
Although most authors have stated that the field position
played does not influence the injury rate,16, 21, 24, 26, 38, 44
Hawkins and Fuller25 found that defenders had a greater
risk of injury than other players. Other studies have
shown that goalkeepers’ injuries occur mostly in the upper
limbs.6, 51
Amount and Standard of Training
Arnason et al.3 showed that teams that had the longest
training period registered significantly fewer injuries dur-
ing the season. Teams with a higher-than-average num-
ber of training sessions sustained fewer injuries. A high
practice-to-game ratio seems to be advantageous.18 Ek-
strand and Gillquist15 attributed 6 of 256 injuries to a lack
of training.
Agre and Baxter1 showed that an absence of muscle
strain injuries appeared to be directly related to the initi-
ation of a controlled warm-up and stretching program. In
the study of Ekstrand et al.,18 all seven quadriceps muscle
strains affected players on teams in which shooting at the
goal occurred before warm-up.
Equipment
Failure to wear shin guards has been shown to notably
increase the proportion of leg injuries.4, 8, 29 In two studies
S-8 Dvorak and Junge
by Ekstrand and Gillquist,15, 16 all traumatic leg injuries
occurred in players who wore inadequate or no shin
guards.
A significant difference has been demonstrated in the
ankle sprain rate of players using ankle tape compared
with those not using it.17 In a prospective study, the
preventive value of special ankle braces has been prov-
en.63 However, stabilometric recordings of players with
and without ankle taping showed that taping did not
influence the stabilometric values.65
Surve et al.59 showed a fivefold reduction in the inci-
dence of ankle sprains in football players with previous
ankle sprains using a semirigid orthosis compared with
the nonbraced group. Based on their review of the litera-
ture, Thacker et al.62 recommended that athletes who
have suffered a moderate or severe sprain should wear an
appropriate orthosis for at least 6 months to prevent a
recurrent ankle sprain.
Shoe-surface contacts are important to football, and fric-
tion resistance must therefore be kept to a minimum.19
Traumatic injuries, such as knee sprains, are usually
caused by twisting of the knee that occurs when the foot in
a shoe with screw-in studs got stuck in the ground.15
Ekstrand and Gillquist15 attributed two-thirds of overuse
injuries to bad-quality footwear. Other authors have also
suggested that the football shoe may be a possible risk
factor for injury.29
Pitch Conditions
Ekstrand and Gillquist15 attributed 24% of their recorded
injuries to unsatisfactory pitches, but they considered that
most injuries were caused by a combination of poor sur-
face and other factors, such as bad-quality shoes, muscle
tightness, joint instability, or inadequate rehabilitation.
Arnason et al.3 showed that significantly more injuries per
hour of play or practice occurred on artificial turf than on
grass or gravel. Differences in the pattern and mechanism
of injuries incurred on artificial turf and on natural grass
have been reported.29 Ekstrand and Nigg19 concluded in
their review that surfaces with artificial turf produce
more abrasion injuries than did surfaces with natural
grass. A comprehensive analysis of the biomechanical as-
pects of different playing surfaces has been performed by
Nigg and Yeadon.45
Rules and Fair Play
The most common mechanism of injury is direct contact
with another player.27 Forty-four percent to 74% of trau-
matic injuries are considered to be the result of physical
contact between players.3, 4, 7, 38, 44 Bjordal et al.9 reported
that tackling was the injury mechanism in 46% of ACL
injuries. Arnason et al.3 showed that sprains were caused
mainly by tackling. In a study by Nielson and Yde,44 80%
of players sustained their first ankle sprain during tack-
ling. They also found that more than half of all knee
injuries were caused by tackling.
American Journal of Sports Medicine
In the 1994 World Cup, 29% of all injuries resulted from
foul play as judged by the referees.25 Players have stated
that fouls are in some way responsible for 25% to 33% of
all injuries.38, 44 Referees have considered that 23% to 28%
of all traumatic injuries are caused by the violation of
existing rules.15, 21
CONCLUSIONS
Inklaar28, 29 concluded that the epidemiologic information
regarding the sports medicine aspects of football injuries
is inconsistent and far from complete. This statement is
also valid in view of more recent studies. More research is
needed to identify high-risk groups and variables that
may predict injuries within these subgroups. Such stud-
ies should include uniform definitions of injury and
should be based on sound epidemiologic and method-
ologic principles.
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players. Arch Phys Med Rehabil 68: 147–150, 1987
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