Results of 2 Decades of Injury Surveillance

and Public Release of Data in the

Australian Football League
John W. Orchard,*y MD, PhD, FACSP, FACSM,
Hugh Seward,z MBBS, DObstRCOG, FACSP, FASMF, and Jessica J. Orchard,y BEc LLB(Hons), MPH
Investigation performed at the University of Sydney, Sydney, Australia

Background: Injuries are common in all professional football codes (including soccer, rugby league and union, American football,
Gaelic football, and Australian football).
Purpose: To report the epidemiology of injuries in the Australian Football League (AFL) from 1992-2012 and to identify changes in
injury patterns during that period.
Study Design: Descriptive epidemiology study.
Methods: The AFL commenced surveying injuries in 1992, with all teams and players included since 1996. An injury was defined
as ‘‘any physical or medical condition that causes a player to miss a match in the regular season or finals (playoffs).’’ Adminis-
trative records of injury payments (which are compulsory as part of salary cap compliance) to players who do not play matches
determined the occurrence of an injury. The seasonal incidence was measured in units of new injuries per club (of 40 players) per
season (of 22 matches).
Results: There were 4492 players listed over the 21-year period who suffered 13,606 new injuries/illnesses and 1965 recurrent injuries/
illnesses, which caused 51,919 matches to be missed. The lowest seasonal incidence was 30.3 new injuries per club per season re-
corded in 1993, and the highest was 40.3 recorded in 1998. The injury prevalence (missed matches through injury per club per season)
varied from a low of 116.3 in 1994 to a high of 157.1 in 2011. The recurrence rate of injuries was highest at 25% in 1992 and lowest at
9% in 2012 and has steadily fallen across the 21 years (P \ .01). The most frequent and prevalent injury was hamstring strain (average
of 6 injuries per club per season, resulting in 20 missed matches per club per season; recurrence rate, 26%), although the rate of ham-
string injuries has fallen in the past 2 seasons after a change to the structure of the interchange bench (P \ .05). The rate of knee
posterior cruciate ligament injuries fell in the years after a rule change to prevent knee-to-knee collisions in ruckmen (P \ .01).
Conclusion: Annual public reporting (by way of media release and reports available freely online) of injury rates, using units easily
understood by laypeople, has been well received. It has also paved the way for rule changes with the primary goal of improving
player safety.
Keywords: football; injury surveillance; injury epidemiology

Injury surveillance is now recognized as an important obli-
gation of professional sporting bodies,14,15,18,38,48 with vari-
ous levels of success reported.36 Australian football is
a unique ‘‘code’’ of football, although it shares characteris-
tics with soccer (aerobic running and kicking by all players,
although punt kicking is generally used) and rugby (upper
body tackling). There are 18 players per team on the field,
*Address correspondence to John W. Orchard, University of Sydney,
School of Public Health, Cnr Western Avenue & Physics Road, NSW 2006
Sydney, Australia (e-mail: john.orchard@sydney.edu.au).
y
School of Public Health, University of Sydney, Sydney, Australia.
z
Australian Football League Medical Officers Association, Melbourne,
Australia.
One or more of the authors has declared the following potential con-
flict of interest or source of funding: The authors receive funding, either
direct or via AFL Medical Officers Association, from the Australian Foot-
ball League (AFL) to provide injury surveillance services for the AFL.
The American Journal of Sports Medicine, Vol. 41, No. 4
DOI: 10.1177/0363546513476270
Ó 2013 The Author(s)
with up to 4 players per team used as interchange/
substitute players (an interchange player is one who can
return to the field again after being replaced, whereas a sub-
stitute must stay off once replacedi). The size of the field is
variable but larger than all other types of football. The pre-
mier professional competition is the Australian Football
League (AFL), which maintains its own website (www.afl.
com.au) that includes multimedia footage of game high-
lights. The AFL is a winter (southern hemisphere from
March-September) league that schedules weekly matches
over 22 rounds of a home-and-away season, with a 4-week
finals (playoff) series. In 2012, the AFL had the fourth high-
est average crowd attendance (32,748) of any professional
sporting competition in the world, behind only the National
Football League (NFL), English Premier League, and Bun-
desliga (www.sportingintelligence.com).
The fifth annual AFL injury report was publicly
released in 1996 (a process that has since been repeated
annually) at a media conference and in the official match
program,40 believed to be the first occasion worldwide

734
Vol. 41, No. 4, 2013
that a professional sport openly tabled its injury data. The
NFL has conducted an injury surveillance system for lon-
ger than the AFL (since the 1980s) but does not publicly
release its data on an annual basis, although multiple
studies based on these data have been published in the sci-
entific literature.12,33,42,43,46,49 Other bodies known to con-
duct regular injury surveillance (with various degrees of
disclosure) include the National Collegiate Athletic Associ-
ation (NCAA),1,6,7 Union of European Football Associations
(UEFA),9,10,18 and Rugby Football Union (RFU).4,5
It is an ongoing aim of the AFL and the AFL Medical
Officers Association to maintain the ‘‘gold’’ standard of
injury surveillance in Australia and to at least match the
best other surveillance systems worldwide. Fortunately,
being a sport primarily played in one country with one
major professional league, the AFL does not need to deal
with a variety of reporting systems and embark on an
international consensus definition of injuries. This specific
report aims to highlight trends over 21 years, particularly
long-term changes in the injury profile.
MATERIALS AND METHODS
The methods of the annual AFL injury survey are now well
established and have been previously described in
detail.35,38 All teams now keep electronic records of inju-
ries. Although teams use different systems, at the end of
the season, injury data from each team are exported into
a common system.
The standard AFL player contracts now include consent
for players’ injury records to be passed from team medical
staff to researchers for the purposes of standard injury sur-
veillance, on the condition that confidentiality is main-
tained over individual player injury records. The methods
of the AFL injury survey have been approved by the AFL
Research Board, which is the appropriate institutional
review board for this type of study.
Injury Definitions and Categories
From 1997 onward, the definition of an injury has been an
‘‘injury or medical condition which causes a player to miss
a match.’’38 Injury data before 1997 were retrospectively
screened to adhere to this new definition. This definition
and methodology have been chosen to promote consistency
across all AFL clubs and from season to season.31 Although
the cutoff for inclusion was that a player must miss
a match, the survey captured injuries that occurred in
AFL matches, lower league matches, training sessions,
and the off-season (as long as a match was missed in the
regular season or finals). Player movement monitoring
essentially requires that all clubs define the status of
each player of each round to be either (1) playing AFL
(national league level) football, (2) playing football at
a lower level (state/minor league level), (3) not playing foot-
ball because of injury (either short or long term), or (4) not
playing football for another reason (eg, suspended or not
selected at the AFL level and not participating in a lower
Injury Surveillance in Australian Football 735
level match that week). Clubs must complete a form in
an Excel spreadsheet (Microsoft, Redmond, Washington),
indicating the status of all players within 72 hours of the
end of each match. An injury is defined by this status,
with the details then requested electronically by the injury
surveillance coordinator at the end of the season for check-
ing and analysis. These details include diagnosis, which is
subsequently coded (using OSICS codes, version 934,44),
and onset of injury. Injury categories (ie, which codes are
included in which injury category) have been amended
slightly over the period of the study, as have the codes
themselves. Any changes to the mapping of codes were
applied retrospectively affecting previous data. The defini-
tion of a condition ‘‘causing a player to miss a match’’
includes illnesses and injuries caused outside of football,
although these injuries are considered in separate catego-
ries when grouped by diagnosis.38
Injury Rates
The major measurement of the number of injuries is sea-
sonal injury incidence. Seasonal injury incidence is mea-
sured in the unit ‘‘new injuries per club per season,’’
where a club is defined as 40 players and a season is
defined as 22 matches. This reflected the average club
list size in the mid-1990s. The average club in more recent
years of the survey has approximately 47 players on the
list and plays slightly more than 22 rounds (including
finals), and therefore, the actual number of injuries occur-
ring per club would be higher in more recent years, but the
figures have been slightly adjusted to maintain consistency
with the earlier chosen definition of a club season.
The major measurement of the amount of playing time
missed through injury is injury prevalence, measured in
the unit ‘‘missed matches per club per season.’’ Injury prev-
alence is linked to injury incidence but includes an addi-
tional unit, injury severity, which is the average number
of matches missed per injury. Because teams are basically
scheduled to play 1 match per week only (similar to the
NFL), an injury severity of 4 matches normally equates
to 4 weeks (approximately once per season, teams are
given a bye week off from playing). Season-ending injuries
record only the number of matches actually missed (rather
than an estimate of the number of matches that would
have been missed if the season had been longer).
The recurrence rate is the number of recurrent injuries
expressed as a percentage of the number of new injuries. A
recurrent injury is an injury in the same injury category
occurring on the same side of the body in a player during
the same season. Therefore, by this definition, an injury
of one type that recurred the following season was defined
as a new injury in that next season.
Statistical analysis of temporal trends in injury rates
over the 21 years was made using the linear regression
(LINEST) function in Excel. Temporal trends were consid-
ered statistically significant if P \ .05. For injury incidence
before and after a rule change, comparisons between injury
incidence were made using the calculation of 95% confi-
dence intervals (CIs).
736 Orchard et al The American Journal of Sports Medicine

TABLE 1
Key Indicators for All Injuries Over a 21-Year Period: 1992-2012

All Injuries, 1992-2002 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Incidence (new injuries per club per season) 35.4 30.3 33.7 38.2 38.9 40.1 40.3 36.9 37.4 35.8 34.4
Incidence (recurrent) 8.8 7.3 6.0 6.2 4.9 8.0 7.6 5.2 5.9 5.5 4.4
Incidence (total) 44.2 37.6 39.7 44.4 43.8 48.1 47.9 42.1 43.3 41.3 38.7
Prevalence (missed matches per club per season) 145.9 122.5 116.3 133.1 140.0 151.2 141.9 135.9 131.8 136.4 134.7
Average injury severity (number of missed matches) 4.1 4.0 3.5 3.5 3.6 3.8 3.5 3.7 3.5 3.8 3.9
Recurrence rate, % 25 24 18 16 13 20 19 14 16 15 13
Clubs participating 12/15 14/15 15/16 15/16 16/16 16/16 16/16 16/16 16/16 16/16 16/16
Average players per club 46.1 44.6 42.5 42.3 44.1 44.2 41.7 41.7 41.4 43.4 43.0

All Injuries, 2003-2012 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Incidence (new injuries per club per season) 34.1 34.8 35.3 34.0 34.6 36.9 37.8 38.7 38.4 38.1
Incidence (recurrent) 4.6 3.7 4.8 4.1 5.6 5.4 3.6 4.7 3.6 3.5
Incidence (total) 38.7 38.5 40.1 38.2 40.3 42.3 41.4 43.3 42.0 41.7
Prevalence (missed matches per club per season) 118.7 131.0 129.2 138.3 146.7 147.1 151.2 153.8 157.1 147.7
Average injury severity (number of missed matches) 3.5 3.8 3.7 4.1 4.2 4.0 4.0 4.0 4.1 3.9
Recurrence rate, % 14 11 14 12 16 15 10 12 9 9
Clubs participating 16/16 16/16 16/16 16/16 16/16 16/16 16/16 16/16 17/17 18/18
Average players per club 42.2 42.8 43.3 43.9 44.2 44.6 46.1 46.4 46.9 46.7

RESULTS
There were 4492 players listed over the 21-year period,
with an average age of 23.6 years (range, 15.9-38.8
years). They played a combined total of 162,683 matches
at the AFL (national league) level and 91,098 matches at
another (lower) level (eg, state league), from a total of
328,181 weeks (possible matches) of exposure. In an
average season, a club would have approximately 1200
player-hours of match exposure and perhaps 4 times
more than this in training exposure (although training
exposure was not measured by this study). There were
13,606 new injuries/illnesses and 1965 recurrent inju-
ries/illnesses, which caused 51,919 matches to be missed.
Key indicators of injury are presented in Table 1. Injury
incidence (new injuries per team per season) has stayed
fairly constant over the 21-year period, varying between
30 and 40 injuries per team per season. As general
trends, injury incidence rose 2.0 per year from 1993-
1998 (P \ .01), fell 1.2 per year from 1998-2003 (P \
.01), and rose 0.6 per year from 2003-2010 (P \ .01).
Injury prevalence (missed matches through injury per
team per season) has followed similar patterns over the
same time periods. Injury incidence and prevalence are
linked by injury severity (average number of matches
missed per new injury), which has been fairly close to
an average of 4 matches missed per injury over the entire
21 years (range, 3.5-4.2 years).
Injury Incidence
Table 2 details the incidence (new injuries only) of all
defined categories, in units of new injuries (ignoring recur-
rences) per club per season. Only the past 10 years are
detailed for space reasons, although averages for the
period 1992-2002 are listed and are able to be compared
with averages for the past decade. Exact category data
from the 1990s are available in earlier publications.38,41
Injury Recurrence
The rate of recurrent injuries has fallen fairly substantially
over the 21-year period (falling 0.6% per year over the entire
period; P \ .001), starting with a high of 8.8 recurrent inju-
ries per club per season in 1992 (recurrence rate of 25%) to
a low of 3.4 recurrent injuries per club per season in 2012
(recurrence rate of 9%). Table 3 shows the rate of recurrence
of some of the common injury types that are prone to a high
recurrence rate. The 2012 season demonstrated the lowest
recurrence rates seen in the 21 years of the survey. Most
contact mechanism injuries, such as fractures, concussions,
and hematomas, have a low recurrence rate. The common
muscle strains have also shown a steady decline in recur-
rence rates over the 21 years (P \ .01 for decline in ham-
string, calf, and quadriceps recurrence rates; P = .06 for
decline in groin injury recurrence rate).
Table 4 details the amount of missed playing time
attributed to each injury category, expressed in units of
number of matches missed per injury per club per season.
Again, only the past 10 years are detailed for space rea-
sons, although averages for the period 1992-2002 are listed
and able to be compared with averages for the past decade.
Clearly, the most common and prevalent injury in the
AFL over the 21-year period was a hamstring strain. There
were 2253 new and 588 recurrent hamstring strains, caus-
ing 7322 matches to be missed. This resulted in an injury
incidence of 6.0 new hamstring strains per club per season,
causing 20.4 missed matches per club per season, with an
average recurrence rate of 26%.
Other than the decreases in recurrence rates, there were
some trends in injury incidence that were significant across
the entire 21-year period. Head and neck injuries have fallen
Vol. 41, No. 4, 2013 Injury Surveillance in Australian Football 737

TABLE 2
Injury Incidence (New Injuries per Club per Season) Over a 10-Year Period: 2003-2012a

Average, Average,
Injury Type by Body Area 1992-2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2003-2012

Head/neck
Concussion 0.8 0.3 0.3 0.7 0.3 0.3 0.4 0.5 0.5 1.1 1.0 0.5
Facial fracture 0.6 0.6 0.8 0.6 0.3 0.4 0.2 0.5 0.5 0.5 0.6 0.5
Neck sprain 0.1 0.0 0.1 0.2 0.3 0.1 0.2 0.1 0.1 0.1 0.1 0.1
Other head/neck injury 0.1 0.3 0.2 0.1 0.2 0.2 0.1 0.1 0.2 0.2 0.2 0.2
Shoulder/arm/elbow
Shoulder sprain and dislocation 0.8 1.3 1.0 1.4 1.6 1.0 1.8 1.3 1.6 1.8 1.3 1.4
Acromioclavicular joint injury 0.9 0.3 1.1 0.8 1.2 0.8 0.7 0.5 0.8 0.7 0.5 0.7
Fractured clavicle 0.3 0.2 0.6 0.3 0.3 0.3 0.1 0.2 0.2 0.1 0.2 0.3
Elbow sprain or joint injury 0.1 0.1 0.3 0.1 0.1 0.1 0.1 0.2 0.2 0.3 0.3 0.2
Other shoulder/arm/elbow injury 0.5 0.5 0.4 0.6 0.3 0.2 0.3 0.1 0.3 0.4 0.6 0.4
Forearm/wrist/hand
Forearm/wrist/hand fracture 1.3 0.8 1.1 1.3 1.1 0.9 1.2 1.1 1.2 1.6 0.8 1.1
Other hand/wrist/forearm injury 0.4 0.7 0.4 0.3 0.3 0.6 0.4 0.4 0.3 0.4 0.5 0.4
Trunk/back
Rib and chest wall injury 0.9 0.8 0.7 0.4 1.0 0.4 0.7 0.3 0.6 0.4 0.4 0.6
Lumbar and thoracic spine injury 1.5 0.8 1.6 2.1 1.5 1.3 1.5 1.4 1.7 1.4 1.5 1.5
Other buttock/back/trunk injury 0.8 0.5 0.6 0.4 0.6 0.5 0.7 0.5 0.4 0.6 0.9 0.6
Hip/groin/thigh
Groin strain/osteitis pubis 3.2 2.9 3.1 2.9 3.3 4.0 3.2 3.3 4.1 2.8 2.6 3.2
Hamstring strain 6.0 5.7 6.3 5.2 6.4 6.7 6.6 7.1 6.0 4.8 5.7 6.0
Quadriceps strain 2.0 2.0 1.9 1.9 1.7 1.8 1.8 2.1 1.7 1.4 1.6 1.8
Thigh and hip hematoma 1.2 0.3 1.1 1.0 1.1 0.6 0.5 1.0 1.1 0.5 0.4 0.8
Other hip/groin/thigh injury, including hip joint 0.2 0.4 0.3 0.2 0.3 0.8 0.8 1.0 0.7 1.0 1.2 0.7
Knee
ACL 0.9 0.6 0.5 0.6 0.9 0.6 0.9 0.7 0.6 0.9 0.8 0.7
MCL 1.1 1.0 0.7 1.0 0.8 1.4 1.3 0.7 0.8 1.0 0.9 0.9
PCL 0.5 0.5 0.7 0.4 0.3 0.2 0.3 0.3 0.4 0.6 0.3 0.4
Knee cartilage 1.4 1.7 1.2 1.3 1.0 1.2 1.6 2.0 1.7 1.5 1.0 1.4
Patella injury 0.3 0.1 0.1 0.3 0.3 0.3 0.2 0.2 0.5 0.4 0.2 0.3
Knee tendon injury 0.5 0.7 0.4 0.7 0.4 0.3 0.3 0.5 0.4 0.6 1.0 0.5
Other knee injury 0.9 0.7 0.7 0.9 0.2 0.8 1.0 1.0 0.4 0.8 0.8 0.7
Shin/ankle/foot
Ankle joint sprain, including syndesmosis sprain 2.3 2.6 2.5 2.5 2.1 2.2 2.5 2.6 3.4 2.9 2.6 2.6
Calf strain 1.7 1.6 0.9 1.9 1.6 1.2 2.0 1.3 1.7 2.1 3.0 1.8
Achilles tendon injury 0.4 0.4 0.2 0.3 0.3 0.4 0.6 0.6 0.4 0.9 0.7 0.5
Leg and foot fracture 0.7 0.5 0.5 0.4 0.7 0.5 0.5 1.0 0.9 0.7 0.3 0.6
Leg and foot stress fracture 0.8 0.9 0.9 0.9 1.1 1.1 0.9 0.9 1.2 1.3 1.3 1.1
Other leg/foot/ankle injury 1.4 1.5 1.7 1.3 1.5 1.3 1.1 1.5 1.7 2.5 2.0 1.6
Medical illness 1.7 2.4 2.0 2.2 0.7 1.9 2.1 2.9 2.1 1.8 2.2 2.0
Nonfootball injury 0.2 0.4 0.1 0.1 0.2 0.2 0.3 0.2 0.5 0.1 0.5 0.3
New injuries per club per season 36.6 34.1 34.8 35.3 34.0 34.6 36.9 37.8 38.7 38.4 38.1 36.4

a
ACL, anterior cruciate ligament; MCL, medial collateral ligament; PCL, posterior cruciate ligament.

0.03 per year over the 21 years (P = .02), whereas shoulder
sprains have risen 0.05 per year over the 21 years (P \
.01). The relative incidence of knee posterior cruciate liga-
ment (PCL) injuries in the years 2005-2010, after a rule
change was made to try to prevent these injuries,ii was
0.46 (95% CI, 0.29-0.73) compared with the previous 5
years.37 The relative incidence of hamstring injuries in the
years 2011-2012, after a rule changei was made to convert
one interchange player to a substitute-only player,30 was
0.81 (95% CI, 0.69-0.94) compared with the previous 5 years.
The relative incidence of knee (anterior cruciate ligament
[ACL]) injuries over the period 1999-2012 was 0.76 (95%
CI, 0.60-0.97) compared with the period 1992-1998.
DISCUSSION
Annual public release of injury data has led to greater
public discussion about injuries and has assisted with
interventions that have individually helped tackle the
injury burden in specific areas.30,37,45 In broad terms,
injury incidence has stayed fairly constant over the
21-year period. Injury recurrence has fallen over the
21-year period, but injury prevalence has slightly
risen. However, in the background of injury reduction
measures has been a tendency for the game to become
faster, which itself appears to increase the risk of
injuries.22,30
738 Orchard et al The American Journal of Sports Medicine

TABLE 3
Recurrence Rates (Recurrent Injuries as a Percentage of New Injuries) Over a 21-Year Period: 1992-2012

Recurrence Rate, %
Injuries, 1992-2002 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 11-y Average

Hamstring strains 45 40 31 29 25 38 36 31 37 25 30 33
Groin strains and osteitis pubis 29 43 33 27 22 36 31 6 16 20 23 25
Ankle sprains or joint injuries 9 28 4 9 11 20 21 9 11 17 16 14
Quadriceps strains 35 19 15 21 26 35 20 20 18 10 17 22
Calf strains 28 26 0 16 15 15 15 17 32 17 13 17
All injuries 25 24 18 16 13 20 19 14 16 15 13 17

Injuries, 2003-2012 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 10-y Average

Hamstring strains 27 22 26 16 22 27 18 14 12 14 20
Groin strains and osteitis pubis 20 24 23 28 39 23 19 20 15 17 23
Ankle sprains or joint injuries 6 11 15 10 20 9 10 5 13 5 10
Quadriceps strains 9 6 20 19 18 15 15 18 7 3 13
Calf strains 14 6 12 7 9 5 0 12 5 6 8
All injuries 14 11 14 12 16 15 10 12 9 9 12

Although the injury definition attracts some criticism,
as it does not include the entire spectrum of injuries (eg,
excluding valid injuries that do not cause a player to
miss a match19), its enormous strength is that a consistent
comparison can be made. For a longitudinal study such as
the current analysis, if a broader definition was used, there
may be a concern about changing thresholds for reporting
an injury by team medical staff over time.31
The units used also differ from those in many other
sports and attract some criticism. Many other sports prefer
to measure injury incidence, for example, in units of number
of injuries per 1000 player-hours or per 1000 athlete-expo-
sures. While these units have benefits from an academic
viewpoint, the public release of the AFL injury makes our
choice of units preferable. A layperson cannot easily concep-
tualize how common an injury is if expressed in units of ‘‘X
per 1000 player-hours,’’ whereas it is easily understood that
an injury with a rate of 6 per club per season is common,
and an injury with a rate of 0.5 per club per season is
uncommon. Similarly, it is easiest for a layperson to under-
stand injury prevalence if expressed in values such as 150
matches missed through injury per club per season.
Although criticism of these choices of units is acceptable,
we believe that we can more strongly criticize sports that
publish injury data using figures that are incomprehensible
to laypeople or, worse still, do not publicly release data.
Approximate conversions to injury rates per 1000 player
match hours (if desired for comparisons with other sports)
can be made using the exposures at the start of the results
(eg, every value in Table 2 could be multiplied by 1000 and
divided by 1200 to give units of ‘‘new injuries per 1000
player-hours of match exposure’’). However, doing so raises
another issue with the ‘‘standard’’ injury incidence units of
how to handle injuries of gradual onset, which do not specif-
ically occur during either training or matches.
Hamstring injuries are the most common injury in the
AFL and are responsible for the highest number of matches
missed through injury. They are also common in other
sports.2,8 In sports where positional requirements vary, ham-
string strains are far more common in positions in which
sprinting is more often required.11 Hamstring injuries typi-
cally occur acutely from a high-intensity event (as per the
100-m sprinter tearing the muscle after 40 m of running)
but occasionally also as an ‘‘overuse’’ injury with specific
onset being difficult to isolate. The majority of hamstring
injuries in Australian football occur in matches, although
some occur during training sessions or by other means.
Known risk factors include player age, history of hamstring
injury, strength deficits, indigenous race, and history of other
injuries (including calf, knee, ankle, and groin inju-
ries).16,24,32,52 Previous analysis of hamstring and other mus-
cle strain data shows a high rate of recurrence.§
The current AFL data suggest that, over the past 21
years, players are taking longer to return to play from
muscle injuries, with recurrence tending to decrease but
severity (using average missed matches per injury as the
measure) tending to slightly increase. Management strat-
egy may have been affected by research showing that
recurrence rates remain high for many weeks after the ini-
tial injury27 and that performance of players is often
decreased in the matches soon after a return from ham-
string strains.51 However, this current study lacks the
detailed ability to separate the relative influences of
a more risk-averse return-to-play paradigm from the
improvements in prognostic accuracy afforded by modern
clinical testing (eg, magnetic resonance imaging scans).
An increased rate of hamstring strains over seasons
2003-2010 was also associated with a significant increase
in the number of interchanges per team over that time
period.30 This trend was investigated over a number of sea-
sons, and injury was one of the reasons, along with
§
References 3, 16, 17, 27, 28, 47, 51.
Vol. 41, No. 4, 2013 Injury Surveillance in Australian Football 739

TABLE 4
Injury Prevalence (Missed Matches per Club per Season) Over a 10-Year Period: 2003-2012a

Average, Average,
Injury Type by Body Area 1992-2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2003-2012

Head/neck
Concussion 1.1 0.6 0.3 0.9 0.3 0.3 0.5 0.7 0.8 2.2 1.6 0.9
Facial fracture 2.0 1.0 2.2 1.4 0.8 0.7 0.5 1.1 1.4 1.6 1.5 1.2
Neck sprain 0.4 0.0 0.6 0.3 0.3 1.1 1.1 0.1 0.1 1.5 0.1 0.5
Other head/neck injury 0.4 0.7 0.2 0.2 1.1 1.6 0.1 0.3 1.3 0.2 0.3 0.6
Shoulder/arm/elbow
Shoulder sprain and dislocation 4.7 5.7 5.9 7.7 10.8 6.4 10.2 7.7 10.9 12.1 9.0 8.7
Acromioclavicular joint injury 2.1 0.7 2.5 1.9 2.7 1.4 1.5 1.2 1.5 2.3 1.0 1.6
Fractured clavicle 1.5 1.0 3.5 1.3 1.7 1.8 1.1 0.6 0.7 0.6 0.6 1.3
Elbow sprain or joint injury 0.5 0.4 0.7 0.4 0.7 0.8 0.5 1.5 0.2 1.3 0.7 0.7
Other shoulder/arm/elbow injury 1.5 1.6 1.6 2.4 1.7 0.7 0.7 1.0 0.3 1.3 2.1 1.3
Forearm/wrist/hand
Forearm/wrist/hand fracture 4.8 2.5 3.9 3.8 4.3 2.3 3.2 4.8 3.4 5.4 3.3 3.7
Other hand/wrist/forearm injury 1.0 2.9 1.2 1.2 0.5 3.1 1.4 0.8 1.1 1.8 1.6 1.6
Trunk/back
Rib and chest wall injury 1.6 1.7 1.3 0.6 2.2 1.9 1.3 0.6 1.3 0.7 0.9 1.2
Lumbar and thoracic spine injury 5.9 2.1 5.4 6.4 5.4 2.8 5.0 4.6 6.9 5.9 5.9 5.1
Other buttock/back/trunk injury 2.0 1.6 2.3 0.7 1.3 1.7 1.3 1.2 1.0 1.7 1.7 1.4
Hip/groin/thigh
Groin strain/osteitis pubis 11.7 13.7 13.3 11.2 14.0 17.5 12.4 11.7 15.3 7.9 6.9 12.3
Hamstring strain 19.7 18.6 21.6 18.6 21.8 24.3 25.8 21.8 20.6 16.5 21.5 21.1
Quadriceps strain 6.1 6.0 4.2 6.4 5.5 5.6 6.5 8.4 6.3 5.7 4.0 5.9
Thigh and hip hematoma 1.8 0.5 1.7 1.6 1.4 1.0 0.6 1.2 1.9 0.7 0.5 1.1
Other hip/groin/thigh injury, including hip joint 1.1 1.5 2.6 1.0 2.3 4.5 3.4 6.9 4.7 5.9 5.6 3.9
Knee
ACL 12.9 10.8 10.1 9.3 14.1 15.1 15.3 11.1 7.8 13.6 13.5 12.1
MCL 3.8 2.9 2.9 3.0 1.7 4.7 4.0 2.3 2.5 3.2 3.5 3.1
PCL 3.1 2.0 6.5 2.7 1.8 1.6 2.2 1.2 3.2 4.8 2.0 2.8
Knee cartilage 6.9 7.0 6.1 7.8 5.7 9.1 8.5 10.7 13.0 7.6 4.8 8.0
Patella injury 1.6 0.6 0.1 0.8 1.2 2.7 1.0 1.8 2.4 1.7 1.1 1.4
Knee tendon injury 2.3 2.9 0.9 2.6 1.8 0.7 1.1 0.8 0.8 2.3 2.8 1.7
Other knee injury 2.4 2.4 1.3 3.8 0.2 2.6 2.7 2.6 0.9 2.3 2.0 2.1
Shin/ankle/foot
Ankle joint sprain, including syndesmosis sprain 5.9 5.3 6.4 9.2 8.1 7.1 7.0 8.9 9.2 8.7 10.7 8.2
Calf strain 4.4 3.8 1.7 4.5 3.4 3.1 4.4 3.0 3.7 5.5 7.1 4.1
Achilles tendon injury 1.4 1.5 0.8 1.9 2.1 2.2 4.1 2.2 3.4 4.0 5.0 2.8
Leg and foot fracture 5.5 2.9 3.7 2.7 5.7 2.7 3.2 7.5 7.6 4.6 4.9 4.6
Leg and foot stress fracture 4.9 5.3 6.3 5.1 8.2 6.8 7.3 11.0 8.5 10.2 8.6 7.8
Other leg/foot/ankle injury 3.7 3.7 4.3 4.2 4.1 4.2 4.6 6.8 5.7 9.3 6.7 5.5
Medical illness 3.0 3.8 4.2 3.6 0.7 3.1 3.5 3.7 3.2 3.2 4.2 3.3
Nonfootball injury 0.9 1.0 0.4 0.1 0.5 1.4 1.1 1.3 2.4 0.5 2.1 1.1
Missed matches per club per season 135.6 118.7 131.0 129.2 138.3 146.7 147.1 151.2 153.8 157.1 147.7 142.6

a
ACL, anterior cruciate ligament; MCL, medial collateral ligament; PCL, posterior cruciate ligament.

congestion in game style and fairness, that led to a rule
change for the 2011 season to restrict unlimited inter-
changes from 4 players to 3 players and introduce a substi-
tute player.i Hamstring incidence over the seasons 2011-
2012 was significantly lower than the previous 5 seasons
(P \ .05). Although it is still too early to assign cause
and effect, it is hoped that this rule change may have
been one of the factors influencing fewer injuries in 2011
and 2012 through the mechanism of decreasing the aver-
age player speed. As more data come to hand (including
ongoing injury surveillance), it is anticipated that future
studies will try to further link average player running
speed, amount of rest, and risk of hamstring injury.30
There have been lower rates of PCL injuries since the
introduction of the center circle rule in season 2005, which
has prevented injuries in ruckmen.37 In the early 2000s,
ruckmen were running at each other from greater distan-
ces, and the ensuing greater momentum from these colli-
sions was associated with greater PCL injuries in
ruckmen. The rule change was able to reverse the increase
in PCL injuries by limiting the distance that ruckmen
could stand apart from each other at the center bounce.37
Injuries of the PCL have remained at historically low rates
since this rule change.
Although rates of ACL injuries have remained fairly con-
stant over the past decade, there has been a statistically
740 Orchard et al
significant lowering of ACL injury incidence in the period
from 1999 onward compared with the period from 1992-
1998 (P \ .05). This coincided with the first observations
that ACL injuries were more common in the warmer parts
of Australia and efforts to change the preparation of the play-
ing surface in response to these observations.23,25,26,29,39
Generally, the rate of head and neck injuries in the AFL
is low, particularly relative to the other football codes that
allow upper body tackling (American football, rugby
league, and rugby union). There has been a gradual tough-
ening of the definition of illegal contact to the head over the
past decade, and recent analysis has shown a reduction in
the rate of facial fractures in the AFL since 2005,45 consis-
tent with the significant decrease in head and neck injury
incidence over the 21-year period of this study (P \ .05).
Concussion has been a focus of previous research in the
AFL, including assessment of safe return to play.21 How-
ever, concussion rates increased slightly in seasons 2011
and 2012. This increase may in part be caused by a more
conservative management of concussions by medical staff
after increased awareness and media focus on the potential
long-term effects of concussions,20,53,54 although the low
numbers of matches missed through concussions make
this hypothesis hard to fully assess.
Although specific examples have been presented of
declines in injury incidence over the 21-year period (some
correlating with specific preventive measures), some injury
categories have increased in incidence over the same time
period, for example, shoulder injuries. While it has been
observed that the number of tackles per match has
increased in conjunction with the increased rate of shoul-
der injuries, to date, this rise in injuries has continued
without any preventive efforts having been successfully
implemented at the competition level.
The AFL, like all professional sporting competitions,
faces an ongoing challenge of delivering a free-flowing, con-
tinuous, and entertaining spectacle while trying to keep
players free from injury (so far as this objective can reason-
ably be achieved in a body contact sport). We believe that
public annual release of injury data has contributed to suc-
cessful injury prevention in the AFL competition. Rule
changes with a view toward improving player safety are
not necessarily embraced by players, coaches, and
fans.13,30,37 However, if there is widespread knowledge of
an increasing injury burden in a certain area (which public
release can disseminate), then acceptance of a rule change
is more likely. We therefore recommend that releasing
pooled injury data should be an automatic obligation of
all professional sports, just as public release of financial
data is an automatic obligation of all listed corporations.
Having vital information like this on the table allows all
stakeholders to put the problem of injuries in proper per-
spective (compared with, say, the ‘‘entertainment value’’
of higher speeds and collisions, which may be the counter-
argument against a proposed rule change).
With respect to PCL injuries, facial fractures, and per-
haps more recently, hamstring injuries, rule changes,
which had their genesis in injury surveillance observa-
tions, have been able to lead to a safer game.30,37,45 These
are specific examples of the AFL being able to follow the
The American Journal of Sports Medicine
paradigm of injury surveillance, both identifying areas
for further research and following the success of
interventions.50
ACKNOWLEDGMENT
The authors acknowledge the medical staff of all AFL
teams that have provided data to the injury survey over
the 21-year period, AFL administration (particularly
Shane McCurry and Adrian Anderson), and also AFL
sports scientists, coaches, and media who have contributed
to an environment where the injury survey is well received
by the industry.
NOTES
i. From 1992-1997, there were 3 players available on an
interchange bench, all of whom could be interchanged
freely (an unlimited number of times) with players on
the field (ie, as per basketball, American football).
From 1998-2010, the number of interchange players
was increased to 4. From 2011, the number of inter-
change players was reduced to 3, and an additional
player was added to the bench as a permanent replace-
ment/substitute (ie, as per soccer, baseball).
ii. To start play (at the beginning of quarters and after
a goal has been scored), the ball is bounced in the center
of the ground. Opposing ruckmen leap to try to tap or
punch the ball to their team’s advantage. From 2005,
a circle was introduced that the ruckmen had to remain
within when the ball was bounced to stop them from
running in from too far away and clashing knees (a
risk for PCL injury).
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