Sporn Med 18 (I): 5~73.

1994
REVIEW ARTICLE 0112-1642194jOOOHJ055jS09.50jO

© Adis International Limited. All rights reserved .

Soccer Injuries
I: Incidence and Severity
Han Inklaar
Medical Department, Royal Dutch Soccer Association, Zeist, and Department of Medical
Physiology and Sports Medicine/Janus Jongbloed Research Centre, Utrecht University,
Utrecht, The Netherlands

Contents
Summary . 55
1, Incidence of Soccer Injuries 57
1.1 Definition. . . . . 57
1.2 Research Design . . 58
1.3 Results . . . . . . . . 61
2, Severity of Soccer Injuries 63
2.1 Nature of Soccer Injuries. 63
2.2 Localisation of Soccer Injuries. 64
2.3 Duration and Nature of Treatment . 64
2,4 Sporting Time Lost . 66
2.5 Working Time Lost . 67
2.6 Permanent Damage , , 67
2.7 Costs of Soccer Injuries. 69
3. Conclusions . . . . . . . . . . 70

Summary Studies on the incidence of soccer injuries have produced a variety of some-
times conflicting results. This may be explained by differences in the definition
of soccer injury and the methods of data collection being used, and by selection
mechanisms in the study populations. The incidence of injuries, therefore, de-
pends on the population being studied. High risk groups exist with respect to age,
gender and level of competition. Competition produces a higher risk of injury
than practice, even when corrections for exposure time are made.
The range of results of studies concerning different aspects of the severity of
injuries may also be well explained by differences in the definition of injury, research
methodology and selection with respect to age, gender, level of play and socio-
cultural background. In countries where soccer is very popular, the healthcare and
social security systems are taxed considerably. On the other hand, soccer injuries
appear to be no more serious than injuries resulting from other sports activities.
A general conclusion is that the epidemiological information of the sport med-
ical aspects of soccer injuries is inconsistent and far from complete. More research is
needed to identify high risk groups and independent predictor variables of injury
within those subgroups . Preferably, such studies should include uniform definitions
of injury and should be based on sound epidemiological methodological principles.
56
Soccer is a very traditional sport. The more orga-
nised play has its origin in the middle of the nine-
teenth century in the English public schools. The
first official rules for association football, or soccer,
were published in 1848. The English Football As-
sociation was the first association to be founded, in
1863.
Currently soccer is one of the most popular sports
in the world. The International Federation of Foot-
ball Associations (FIFA), founded in 1904, involves
186 countries with a total of about 200 million li-
censed soccer players.lll It is estimated that there
is an equal number of unlicensed soccer players.
In Europe, soccer is the most popular sport. The
European soccer organisation (UEFA) represents
49 countries with 20 million licensed players.l-l
In The Netherlands, for example, the Royal Dutch
Soccer Association (KNVB) involves about 1 mil-
lion licensed players in a total population of about
15 million people.
In the last decade different types of indoor soc-
cer have been introduced in many countries, com-
plementary to the traditional outdoor soccer. The
five- a-side type of indoor soccer is now officially
adopted by the international soccer organisations
for the European and World Championships. In this
review article, however, only the medical aspects
of outdoor soccer are discussed .
Outdoor soccer is played by both sexes in dif-
ferent age groups. It is a team sport normally in-
volving 10 field players and I goalkeeper perteam.
An outdoor soccer game is played on a field max-
imally 68m wide and 105m long with a surface
mostly of grass, and sometimes of sand, gravel or
artificial turf. A regulation game consists of 2
halves lasting 45 minutes each with a IS-minute
break at half time . Exceptions to these rules are
made for the younger age groups and for female soc-
cer players. For the younger age groups, games are
generally played on smaller pitches and for a shorter
time. Female soccer games are also shorter.
Physiologically, soccer is characterised as high
intensity, intermittent noncontinuous exercise.Pl
Functional activities include acceleration, decelera-
tion, jumping, cutting , pivoting, turning and kicking
Inklaar
of the ball. Players cover approximately 10km of
ground per game, of which 8 to 18 % is at the high-
est individual speed. In higher levels of competition
there is a greater number of tackles and headings.
The number of headings in a game in elite soccer
in England and Norway, both countries with a play-
ing style involving many headings, is about 100.l 41
A great percentage of the game is performed at
maximum speed. The average aerobic energy yield
during a game in elite soccer is about 80% of the
individual maximum. The average blood lactate con-
centration during a game is 7 to 8 mmollL with peak
values above 12 mmollL. Most players have empty
glycogen stores at the end of the game, are hypo-
hydrated and have increased body temperature.l-l
Soccer is a ball sport and a contact sport, and puts
many demands on the technical and tactical skills
of the individual player. Because of the popularity
and the characteristics of soccer, a vast number of
soccer injuries may be expected. In a prospective
study of sports related injuries in Dutch school
children, Backx et aLl5] showed that the risk factor
combination of outdoor sports, sports with a high
jump rate and sports with physical contact explains
78% of the total variance in the incidence rates of
injury per type of sport. Indeed, many soccer inju-
ries are seen by general practitioners (GPs) and the
emergency and traumatology departments of hos-
pitals. For example in The Netherlands, of all ac-
tivities in leisure time leading to accidents, soccer
was the first in a ranking based on the absolute
number of accidents times the seriousness (fre-
quency times nature of medical treatment) of the
accidents.£6] Outdoor soccer injuries are estimated
at 29% of all sports injuries.Pl Almost 800000 out-
door soccer injuries were sustained in 1987, of
which 340 000 injuries needed medical treatment
(table I).
The aim ofthis article is to review studies on the
epidemiology of soccer injuries. Issues like the in-
cidence and severity of soccer injuries are explored
to give an insight into the current knowledge on
these topics. Specific methodological aspects are
reported in the corresponding sections if they are
relevant for the interpretation and discussion of the
Incidence and Severity of Soccer Injuries
Table I. Estimated absolute number of medically treated injuries in
The Netherlands (source: nationwide population surveyl7J)
Ranking Activity Absolute no.
of injuries
1 Outdoor soccer 340000
2 Indoor soccer 82000
3 Volleyball 68000
4 Jogging 54 000
5= Field hockey 46 000
5= Indoor tennis 46000
results. Recent information and new ideas/con-
cepts about different aspects of the soccer injury
epidemiology will lead to a critical appraisal of the
conclusions and recommendations from past stud-
ies. A follow-up article[8] examines the aetiology
and prevention of soccer injuries.
This literature review is restricted to cohort
studies of the past 15 years. This restriction has two
major reasons . First, in the early 1970s a new tac-
tical system was introduced in elite soccer. This
so-called total soccer system allows players to
change positions constantly throughout a game.
Defenders now also became attackers; attackers
were forced to assist the defence, and players, as a
consequence, have to cover more ground in a game.
Total soccer is predominantly played in 2 different
ways: with the emphasis on the attack and pressure
on the defence of the opponent (e.g. the Dutch way
of play) ; and with the emphasis on the defence
thereby using counterattacks (e.g. the style of play
of teams from Italy, Belgium and Norway). In both
circumstances, more often more players are active
in a restricted area of the pitch with more risk of
physical contact. Total soccer has changed the
character of a game dramatically and may also
have influenced the risk of injury. Total soccer has
now been adopted worldwide. Secondly, almost no
cohort studies of soccer injuries are found in the
Ii terature before the mid-1970s.
1. Incidence of Soccer Injuries
1.1 Definition
Soccer injury, in general, implies all types of
damage occurring in relation to soccer. No common
© Adis International Umlted . All rights reserved.
57
operational definition of soccer injury exists . Var-
ious studies of the incidence of soccer injuries have
% of total no.
of injuries
different definitions of soccer injuries. Awareness
29.1 of the differences in these definitions assists in in-
7.0 terpreting and comparing reported results. Differ-
5.8 ences in definition of soccer injury at least partly
4.6
explain the differences in incidences found.
3.9
In some studies a soccer injury is defined as an
3.9
injury sustained during soccer for which an insur-
ance claim is submitted.l 9-21] In other studies the
definition is confined to injuries treated by a GP122/
or at a hospital casualty or traumatology depart-
ment)13,I7,23-43]
In these studies the population at risk is un-
known. The relatively high percentage of soccer
injuries probably reflects the popularity of soccer
in the countries involved.
The registration of soccer injuries through in-
surance files and medical channels has the dis-
advantage that predominantly more serious and
acute injuries will be recorded. The less serious
and overuse injuries are likely to be missed.l 44 ] For
example, a national survey on sports injuries in
The Netherlands with a broad and subjective defi-
nition of sports injury indicated that only 43% of
all injuries were found to be medically treated.I"l
Meaningful comparison of data from different
soccer injury studies and compari son of soccer in-
jury data with those reported for other sports re-
quire an universally accepted definition of in-
jury.[45] The definition of injury, therefore, should
consist of a set of criteria to separate the injured
from the noninjured soccer players)46]
Several authors suggest that time lost from prac-
tice and games should be included in the statis-
tics)44-48] However, this criterion has not only a
strong subjective component from one player to
another, but there is also a bias through level of
play, type of sport and medical treatment.l'lf The
availability of proper first aid, medical treatment
and rehabilitation, for example, may at least partly
determine the time lost from practice or play. De-
lay by patients and doctors may also playa role.
When time lost from practice and play is used as
Sports Med. 18 (1) 1994
58
a criterion for determining injury, the amount of
time must be clearly stated.f 46l
A second criterion is the need for medical treat-
ment[46,48l Medical attention is defined as any treat-
ment given by a physician, physiotherapist or
trainer. As stated previously, the access to medical
facilities and the quality of medical facilities are
probably not the same for different subgroups in
a soccer population, and also may vary between
countries.
The third criterion involves anatomical tissue
diagnosis. This is the most objective method to de-
termine if an injury has occurred.[46] Tissue diag-
nosis implies that a medical examination by a qual-
ified person, e.g. physician, has been performed.
A fourth criterion, adverse social or economic
effects, was proposed by the Council of Europe.l48l
Here also selection bias most likely has to be ex-
pected.
Sporting time lost is the criterion most often
used in the definition of soccer injury, followed by
medical treatment and tissue diagnosis. Adverse
social or economic effects are also used by
Kristiansenl'v'l as a criterion.
1.2 Research Design
The extent to which soccer injury incidence can
be assessed accurately depends on: the definition of
soccer injury; the way in which incidence is ex-
pressed; the method used to record injuries; the
method used to establish the population at risk; and
the representativeness of the sampleJ50]
With a knowledge of the exposure of a soccer
player to injury, a calculation of risk can be made
and the biases of drawing conclusions from injured
soccer players alone (i.e. case series) can be
avoidedJ 51l
When examining the incidence of injury in soc-
cer players , a retrospective study is usually inferior
to a prospective study because of inconsistencies
in medical records, attendance records and mem-
ory bias. A month after injuries are sustained, un-
derreporting will start to occurr. Registrations us-
ing a retrospective period of more than 30 weeks
are considered to be unreliableJ52) For example,
Inklaar
Ekstrand and Gillquist,[53J in a study on the fre-
quency of muscle tightness and injuries in soccer
players, introduced a retrospective period of one
year. Hoff and Martin[54] used a retrospective pe-
riod of one soccer season. Bernklau and Wollein[55)
and Brynhildsen et al.[56] even analysed past inju-
ries from the career of the selected female soccer
players, as did Berbig and Biener[57] with interna-
tional goalkeepers.
Table II presents the designs and methods for
data collection for the soccer injury epidemiology
studies. The methods of data collection strongly
influence the validity of the findings on the inci-
dence of injury. Due to interindividual differences
in pain tolerance, the category 'uninjured players ',
probably includes injured players. In almost every
study the player decides whether he or she is in-
jured and whether he or she will report this injury
to the authorities.
Also, the category 'injured players' could in-
clude noninjured players or players with injuries
not sustained during regular soccer activities. This
category could be refined by excluding those inju-
ries that do not meet the injury definition and by
medical examination. Therefore, to improve valid-
ity observation of games and practice with sub-
sequent interview and medical examination is pre-
ferred. Observational analysis may only be possible
and present valid information if the aims of the
observation are clearly defined, appropriate meth-
ods of observation including the use of technical
aids are applied, and if a viable means of evaluating
the observation is developed and applied.[82]
Ekstrand and Gillquist[63] showed that one-
third of the moderate and major injuries occurred
within 2 months of a minor injury, therefore, minor
injuries should be recorded.
The representativeness of the study population
will be affected by aspects of selection. The inci-
dence of soccer injuries is highly determined by se-
lectionJ83] Four kinds of selection are recognised.
• Self-selection (personal preferences) and/or se-
lection by social environment (e.g . parents,
friends, school). For example, a boy wishes to
play soccer because all of his friends play soc-
Incidence and Severity of Soccer Injuries 59

Table II. Soccerinjuryepidemiology studies

Reference Design Data collection
McMasterssJ Cohort Trainer
Nilssonand Roas[S9j Cohort Medicalstaff on field
Resnick l60) Cohort Trainer
Pontanoet a1. 161] Cohort 5 newspapers
Sullivanet al.(62J Cohort Coach
Ekstrand and Giliquistl53J Retrospective Personal interview
Ekstrand and Gillquistl63] Cohort Coach
Ekstrand et al.lssJ Randomised trial (cohortstudy with Coach
concurrent control)
Albert[66J Cohort Trainer
Kristiansen[49J Cohort Observation and personalinterview
Berbigand Bienerls7] Retrospective Mailedquestionnaire, response 50%
Bernklau and Wollein[SS] Retrospective Mailedquestionnaire, response 93,6%
Jorgensen(67] Prospective Mailedquestionnaire, response 79%
(Self) registration by playersand coach
McCarroll et al.[68J Cohort Coach
Schrnidt-Olsen et al.[69J Cohort Medicalstaffon field
Maehlurn et al.[70J Cohort Medicalstaffon field
Hoff and Martin(54] Retrospective Mailedquestionnaire, response 62.9% (WMSL);
response 60.6% (MSC)
Eriksson et al.(71J Cohort Coach
Lysensl72] Cohort Physical therapist
Poulmedis(73j Cohort Team doctor
Jorgensen and Sorensen(74J Randomised trial (Self) registration by playersand coach
Backouset al.(7SJ Cohort Trainer
Moller-Nielsen and Hammar76) Cohort (Self) registration by playersand coach
Nielsen and Yee(7?] Cohort Coach
Ekstrand and Troppl78J Cohort Coach
Engstrom et al.(79] Cohort Trainer
Brynhildsen et al.[561 Retrospective Personal interview
Schmidt-Olsen et a1. 180) Cohort (Self) registration by playersand coach
Engstrom et al.(81J Cohort Medical students
Backx et al.151 Cohort Schoolchildrenself reporting

cer. Another player may end membership of a
soccer club because of an injury.
• Selection in the soccer club by others (e.g. the
coach). Soccer players are selected for certain
teams for their soccer skills, physique, physical
characteristics and personality traits. Further-
more, the team for which a player is selected
also will influence these parameters.
• The national and international soccer organi-
sations have selection criteria for age, gender
and level of play. Rules of play, however, are
adjusted for certain age groups, female players
and level of play.
• Selection based on social, medical and biologi-
cal factors. For example, a cohort of soccer
players of around thirty years of age differs
from a cohort of soccer players of an age of
around 15 years on all 3 factors . The older play-
ers mostly have a job, a longer injury exposure
and are biologically' mature .
Selection may reflect the behaviour of soccer
players and the circumstances under which a soc-
cer game is played and soccer players are practis-
ing. The behaviour of soccer players is directly re-
lated to the risk of injury because actions of players
directly determine the (anatomical) tissue load.f84 ]
Table III. Inc idence of injury in cohort studies and retrospective studies . g
Referen ce Gender No. of Population Duration of study No. of inju ries in No . of injuries per 1000 No. injuries per 1000
players pral ice and games' hours of practice and athletes expos ures
games'
McMaster58] M 15 ASL professionel 1976-1977 season 60
Nilsson and Roas l59] M, F 25000 Adolescent 1975 and 1977 tournament 858 M 14
F 32
Resnickl60) M 1090 University teams 1975, 1976 , 1977 season 1975 ,18.1"
1976 ,17.6"
1977 ,17.4b
Pantano et al. (61) M 16 team s 1st League Ilaly 1976/1977 and 1977/1978 628
season 600 .
Sullivan et al. l62J M 931 58 teams, 7-18 years 1979 spring season 19 0.5
F 341 22 teams 15 1.1
Ekstrand et al.[65] M 180 Amateur senior division IV, 1980 sea son 125,131 7 .6,16.9
12 teams
Albert'''1 M 56 NASL pro fessional 1979-1981 outdoor 106 1981 ,0.01
and indoo r seasons 36 1982 ,0.0085
Kristiansen l49] M 6-11 years Toumament, 35 games 114 6.7
Berbig and Beiner57J M 190 International goalkeepe rs 907
Bernklau and Wolie in l5SJ F 117 10 teams, 2 levels of 107
competition
Jorgensen l67) M 383 1st, 2nd, 3rd division 1981/1982 season 521 4 .1
McCarroll et al. l68) M,F 4018 8-18 yea rs 1982 spring season 176
Schmidt-Olsen et al.[691 M 5275 9-19 years 2 tournaments in 1984 229 16 .1
F 1 325 117 29 .1
Maehlum et aIY O] M 1526 <14 -18 yea rs 1984 Norway Cup tournament 266 9 .9
F 514 145 17.6
Hoff and Martin[64J M 455 8-16 years 1984 WMSL outdoor competition 13,33 7 .4
M 366 8-16 years 1984 MSC indoor competition 4 , 70 45 .2
Eriksson et al.[71) M 40 Amateur division IV January -November 54
Lysens 172J M 284 1st division , Belgium 1980-1981 season 166,497
Poulmed isl7:l) M 25 tst division , Greece 1 season 53
Jorgensen and M 395 Series 1 and 5 1987 sea son 228 14.6
S6rensen i14J league, Denmark
Backous et al ,[75) M 681 6-17 years Summer soccer camp 109 7 .3
F 458 6·17 years 107 10.6
Moller-N ielsen and F 86 1st, 2nd, 3rd league , Sweden 1 year 62
Hammar7S]
Nielsen and Yde[77) M 123 1 club 1986 sea son 43,66 3.6,14.3 I '"~
-e
Incidence and Severity of Soccer Injuries 61

The analysis of the soccer injury epidemiology

.~ I studies presented in table 1II shows that each study
:~ is biased by one or more selection criteria.
'0

~:::l
I 1,3 Results
c:
~ ai Like other activities in daily life, playing soccer
:i r-: '" ~ :~ g, has a certain risk of injury. Risk is basically ex-
+!
CC!
.....
+!
,..,
Q)
+!
ell
<0
~
+!
"'t'
:5
c:
Q)
-:Ql
<D
pressed asas..imCIidence,
.
whiIC h iIS d e fime d as the num-
C\l. ~. ~ ~. .~ 8 ber of new cases of a disease arising in a defined
~ ~ ~ .~ '" ~ ~ .~ ~ population during a given period of time.l 85] In this
so '"
«i..; ~
.,; 000 ..:,..;
"''''' III ~ ~
..: «i M ""
M ,.: "
..;' . 0
E 5l
:::l defi100tlOn,
. . a rate 0 f d"isease IS presented Wit . h a nu-
2 ~ merator (number of new cases) and a denominator
-i ~ (defined population at risk).
~ ~ As a consequence, the incidence rate of soccer
i ~ injuries is defined as the number of new soccer
~
'"
eo
co
C\l
III
C\l III
co
co
~~""
C\l co liliE ~
==
injuries during a particular period divided by the
C\l C\l C\l C\l '" ~ Qj' total number of soccer players at the start of the
~ ~ period. However, this definition implies that every
~ ~ soccer player is equally exposed to injury. This is
§ § not the case, Risk may vary with position played,
$ &J actual rather than average time played, or intensity
~ .~ and nature of activity during practice or games,
c: en ~ ~ Exposure has to be accounted for to get a true in-
0; ~ 0; 0; ~ ~ € jury rate.l 86l Also, the risk of injury per player per
~ ill ~ ~ ~ [ ~ hour of participation allow s for a comparison of
-= en ,S ~ the risk of injury for different sports. Using this
~ :§ ~ ¥ I ~ criterion, van Galen & Diedricksl/l ranked indoor
~ ~& ~ ~ ~ soccer in The Netherlands with the highe st inci-
~ en E ~ E ~ :~
=
~ ~ .i~ 1 dence of injuries (table IV).
;en ~c: IIE ~
Ol
;;;
Ql
sOl .§Ol '6> -;; -
~ ~
CD
.~ t)
Ul
Th e d'istnibuti
ution 0 f hirgh n. sk sports WI'II vary
~j ~ ~ ; ~ ~ ~ :~ ~ ~ l!!:S 8. between countries according to differences in the
~.~ ~ ~ ~ ~ ,~t ~ ! '~ t ~ ~ popularity and pattern of sports. For example, in the
'~ :~:~
CJl-c o
:~
o
:~
o
:~
Cl
~;: .~;i; ~ ~ 2
CJl~ CJl ~ W '"
~
~
US, American football rank s number one with a
~ II much high er risk of injury than soccer.l 16.24,60,87]
11l
(0
~
..-
~
.....
~
.....
::j: ;b ~ 'II::t
~ ~ (')iD I '~f?
.....
1jJ
:!:
Table III presents the incidence of injury fig-
~ J!i ures of cohort studies and retrospective studies
~
c:
~ in soccer. Soccer injury incidence is expressed
u.• ,~OJ ~ in many studies as the number of new soccer in-
:::;; :::;; u.:::;; u, :::;; ~ <Ii ,,* juries per 1000 hours of participation in soc-
- ~ f!! Ql en E cer [5,7,49,54,59,62,65,67,69,70,74,75,77-81]
~a. _ ::, ~~.~oS! ' .. , .
e ~ ~ ~i § ~ :~ ~ Only m a limited number of studies were atten-
';; ~ a; iii ~ l[ ~~ $ ~ dance records for games and practice kept, mostly by
16 Ql ~ 5 Ql cij ~ ,~ ~ ,g the trainer or coach of the team [60,65,66,72,75,77·79,81]
-g :5 B;5 :~Qi~1ii~ '~ . . "0 • •
~
rn
tl
C>
~ 'E tl Jl
~nC)O
ill <5 l!?
..0
s: In two studles,l60,66] the n sk of mJury IS presented
ill Jj CD rJj Jj &l <lJ .0 ~ according to the National Athletic Injury/Illness
62
Table IV. Incidence of sports injuries per 1000 hours by medical
treatment in The Netherlands (source : nationwide population
survey[7])
Sport Treatment
medical nonmedical
Indoor soccer 3.7 5.0
Field hockey 2.5 4.0
Outdoor soccer 2.8 3.4
Koriball 2.6 3.0
Handball 3.1 2.3
Reporting System (NAIRS) criterion, i.e. the num-
ber of injuries per 10 000 athlete exposures. How-
ever, a time factor is missing.
To identify certain activities in soccer (games vs
practice, certain practice drills or practice games)
the risk of injury for those activities should be cal-
cul ated by including the number of new injuries
during those activities divided by the number of
soccer players actually exposed multiplied by the
amount of time spent on these activities.
The distinction between the risk of injury in games
and practice is made in a few studies .l5.65.77-79.81]
The risk of injury during games proves to be 3 to 4
tim es higher than the risk during practice. Ek strand
et aI.l65) noticed that a training camp in the prepa-
rat ion peri od for a competition had an incidence of
injury of 21.3 ± 15.2/1000 hour s, almost three times
the risk of injury in practice during the competition
period.
Despit e inconsistency in the research data be-
cau se of the variety of definitions of injury and the
variety of calculations of the incidence of injury,
it see ms that the risk of injury is influenced by
age , gender and level of play. Th e incidence of soc-
cer injuri es appears to increa se with the age of
play ers.[7.54.62.68.69.80]
Sullivan et al. 162J and McCarroll et al.,[68] in stud-
ies on youth soccer did not, however, cons ider ex-
posure time for the different age groups. Two other
studies on youth soccer[59,70J could not confirm
the se re sults. Most of the data are derived from
studies of soccer injuries sustained during tourna-
ments[49 .59.69,70] and a summer camp.l75] The in-
cid ence of injury is much higher in the se circum-
© AdisInternotlonal Limited . All rights reserved.
lnklanr
stance s than found in studies of injuries in youth
competitions.154.62,80j
Thi s difference incidence lev el s may be ex-
total
plained either by the intensity of activity or by dif-
8.7 ference s in the injury reporting system, with a more
6.5 ea sy access to the medical staff during a tourna-
6.2 ment or summer ca mp. Based on inc idence of soc-
5.6
cer inj uri es per 1000 hours of regular games male
5.4
senior socc er players sustain, more injuries than
youth players.l 5.7,54.65.74,77-80J
In the 14 to 16 years age group there see ms to
be a sudden increase in the inciden ce of in-
jury.l7 ,54.62.68,69.75,80J The incidence of injury in
youth pla yers (16 to 18 years of age) is similar to
the incidence of senior players.l 77J Pubertal matu-
rity and growth spurt may lead to an increase in
body height, mu scle mass and, as a con sequence,
higher speed and momentum, \cading to higher
joint reaction forces and higher impact for ce s on
collision.l'Pl Backou s et al. ,l75J using height and
grip stre ngth as parameters of maturity, noticed a
significantly (p < 0.05) higher incidence of injuries
among tall and weak boys compared with imma-
ture (short and weak ) and mature (tall and strong)
boy s. These findings were explained by a tempo-
rary set-back in co ordination and lack of strength
as risk factors .of inj ury. Also, a more aggressive
play and greater risk-taking behaviour associated
with maturity were postulated as risk fac tors .
For femal e soccer players the effect of age on
the incidence of injury is not yet cle ar. Onl y three
studies were conducted, and they show conflicting
data as to the increase in the incidence of injury
with incr easing age groups.[69.70.811 In contras t to
Schmidt-Olsen et aJ.)69j who showed an ex ponen-
tial increase in the incidence of injury per 1000 hours
of play from the age gro up 14 to 16 years to that of
17 to 19 years, Maehlum et aU 70J regi stered the
highest incidence of injury in the age group 14 to
16 years , and found a decline in the incide nce of
injury per 1000 hours of play in the age group 17
to 19 years. The incidence of injury per 1000 hours
of play for senior female soccer players in the study
of Engstrom et al.l 81J was inbetween the incidence
Sports Mad. 18 (1) 1994
Incidence and Severity of Soccer Injuries
figures presented for the age group 17 to 19 years
in the other two studies.
Female soccer players show a higher incidence
of injury than male soccer players in youth play-
ers[59,62,69,70,75,S91 and for elite senior piayers.l S1l
The higher incidence of injury in females has been
attributed to a lower level of playing techniques
and skills,l59,69,701 and a relative lack of physical
fitnessJSl]
Moller-Nielsen and Hammar[76] showed in a
prospective study that women soccer players are
more susceptible to traumatic injuries during the
premenstrual and menstrual period compared with
the rest of the menstrual cycle (p < 0.05). Women
using contraceptive pills had a lower rate of trau-
matic injuries than nonusers, even when matched
for age (p < 0.05). Nevertheless, selection bias may
be responsible for these findings .
The level of competition has been associated
with the incidence of injuries per 1000 hours of
game or practice by Nielsen and Yde l77] and
Ekstrand and Tropp.17S! Both studies showed a
higher injury rate during games for players in
higher levels of competition and a higher injury
rate during practice for players at lower levels of
competition, although this is not statistically cor-
roborated. These results were explained by differ-
ences in intensity and speed in the game, in phys-
ical characteristics and training conditions.
2. Severity of Soccer Injuries
The severity of soccer injuries can be described
on the basis of the following criteria: (i) nature of
soccer injury; (ii) duration and nature of treatment;
(iii) sporting time lost; (iv) working time lost; (v)
permanent damage; and (vi) cost.[441
The location of the soccer injury is used to add
relevant information about the injury . For example,
a sprain of a finger joint is considered to be a less
serious injury for a field player than a sprain of the
ankle joint.
2.1 Nature of Soccer Injuries
A widely used international classification con-
cerning the type of musculoskeletal injuries is a
63
part of the international classification of diseases
(ICD-CM-IO) by the World Health Organization.
For sports injuries, a simplification of this rather
complicated classification was first suggested by
Thorndike[901 and presented by the American Medi-
cal Association,f9lJ Williams[921 and Lysens and
Ostyn.l 93]
The currently used classification gives the fol-
lowing categories of medical diagnosis: sprain (of
joint capsule and ligaments); strain (of muscle and
tendon); contusion (bruising); dislocation or sub-
luxation ;fracture (of bone); abrasion (graze); lac-
eration (open wound); infection or inflammation;
concussion.
Also, a classification into traumatic (acute and
chronic) and stress (overuse) injuries may be used
since different mechanisms are involved in the ae-
tiology of these injuriesJ63,64,S41 Strains are gen-
erally considered to be acute overuse injuries.
A reliable diagnosis of injury requires a medical
examination by a physician. In general, this goal is
realised in studies based on insurance claims and
injuries treated at a GP 's practice or at a hospital
casualty or other medical department. In popula-
tion based studies, however, this is not always the
case . The National Athletic Injury/Illness Report-
ing System, for example, relies upon the diagnosis
made by a qualified athletic trainer.
As previously stated, if soccer injuries are re-
corded through insurance claims and medical
channels, a fairly large percentage of serious, pre-
dominantly acute injuries will be observed and
less serious and overuse injuries will not be re-
corded. This is reflected by the high percentage of
fractures .[16,26,30,36,41,43]
Although sufficient statistical corroboration is
lacking, some tendencies can be observed : con-
tusions, strains and sprains account for most of
the injuries in the population based studies for all
the selected subgroups. Youth players sustain more
contusions and fewer overuse injuries (strains
and tendinitis/bursitis) than do senior play-
ers .149,58,59,63,66,69,70,73,77,79,81j In youth soccer,
boys have a higher percentage of laceration and
a lower percentage of sprains than girls.[ 701 No
64
difference is seen, however, between senior female
soccer players and male soccer piayers.l63,79,81 J
In professional soccer, a higher percentage of
strains is registered than in senior amateur soc-
cer.l63,66,73,77,79]
In senior soccer players about two-thirds of in-
juries have a traumatic origin; about one-third of
the injuries concern overuse injuries.l 64,66,77 ,79,81]
Ekstrand and Gillquist l64J and Engstrom et al. I79J
noticed that two-thirds of the traumatic injuries
occurred during games. Overuse injuries were seen
most often during preseason training .
As might be expected, goalkeepers seem to have
a different distribution according to the nature of
injuries. Despite the limitations of their study,
which are the unrestricted retrospective period and
selection bias, Herbig and Biener l57] recorded
higher percentages of dislocations and fractures
among goalkeepers compared with field players.
2.2 Location of Soccer Injuries
Expressed as a percentage of total injuries,
lower extremity injuries represent 6] to 90% of
the total number of injuries in the cohort studies.
The most common locations of soccer injuries are
the ankle and the knee.l7,59,61,63,64,68,69,73,77,79-8 I]
Goalkeepers, however, have more head, face, neck
and upper extremity injuries than lower extremity
injuries.l 57]
Some studiesI59,62,701 show a higher incidence
of head, face and upper extremity injuries among
youth players but other studies[49,69,80) do not sup-
port these findings. Possible explanationslt'" for a
difference in location of soccer injuries between
youth players and senior players are highly specu-
lative, and there is a need for further study.
An effect of gender and the location of soccer
injuries has not yet been demonstrated. In profes-
sional soccer, a tendency is shown for a higher per-
centage of hip and thigh injuries,161,66.73] although
this is not statistically corroborated. Also, for stud-
ies based on insurance claims and hospital casualty
records, the picture is not quite clear.
Sprains of the foot, ankle and knee and strains of
hamstrings, quadriceps, adductors and gastrocnemius
lnklaar
are common injuries. 158,59,63,64,68,69,73,75,77-79] The
incidence of these types of injuries vary consider-
ably between the studies. Age and level of play ap-
pear to be important confounders. Many studies
demonstrate that-in youth soccer contusions of the
lower leg are the most common injuries.159,62,68-70,7S]
The most common chronic overuse injuries in
male senior amateur players are adductor tenosyn-
ovitis and achilles tendinitis,l63 ,64] and for female
senior soccer players shin splints and iliotibial tract
tendinitis.l 56] The different types of overuse injury
in female soccer players may be explained by a higher
frequency of alignment variations of the lower ex-
tremity, such as genu varum or valgum, squinting
patellae, tibia varum and pronated feet.
For goalkeepers, a different injury pattern is no-
ticed,IS7] the most common injuries are dislocation
of fingers (16%), concussion (9%), dental damage
(5.1%) and sprains of the hand (4.7%).
2.3 Duration and Nature of Treatment
Data on the duration and nature of treatment can
be used to determine the severity of an injury, es-
pecially what therapies are used. 1M] Registration
of the duration and nature of treatment enables
comparison of the effectiveness of different treat-
ment programmes in terms of sporting time lost
and cost -benefit. For policy makers in government,
municipality and sports organisations, it is impor-
tant to know which part of healthcare budgets are
allocated to sports injuries in general and to soccer
injuries in particular. The relative safety of soccer
can be estimated by comparing the duration and
nature of treatment of soccer injuries with those
consequences of injuries resulting from other
sports activities.
Studies using duration and nature of treatment
as parameters of the severity of injuries are, how-
ever, most probably biased by the level of play and
the sociocultural background with corresponding
differences in availability of and access to medical
care and rehabilitation. Van Galen and Diederiksl/l
conducted a telephone survey in a representative
sample of 25 118 people in 9068 households. Every
month a new sample of households was questioned
Incidence and Severity of Soccer Injuries
about all types of accidents sustained and about
participation in sports by individual members dur-
ing the preceding 4 weeks. Special attention was
paid to the nature of treatment. Treatment by the
club trainer and self treatment were considered as
no medical treatment. Five types of treatment were
registered (see table V). Because of the study de-
sign, there was an underreporting of chronic over-
use injuries. 92% of the soccer players contacted
were registered. The incidence of medically treated
soccer injuries was 2.8 injuries/lOOO hours with an
overall incidence of 6.2 injuries/lOOO hours. In-
klaar l22] reported that 58% of first consultations of
GPs for sports injuries in The Netherlands are on
account of soccer. The population at risk is, how-
ever, not quite clear.
De Loes l39] conducted a prospective study of
acute sports injuries over 1 year from total popula-
tion of a municipality with 31620 inhabitants, in
Sweden. 571 sports injuries were recorded, and
these accounted for 3% of all acute visits . Soccer
accounted for 241 (42%) of all sports injuries and
represented 41 % of the visits to the open ward of
the hospital and 29% of the days spent in a hospital.
The part of outpatient care needed for soccer inju-
ries was proportionate to the percentage of sports
injuries caused by soccer. However, a reference
population of soccer players was not presented
with the de Loes[39] study.
In 1986, the ongoing registration of the Dutch
Home and Leisure Accident Surveillance Sys-
tem[43] registered a total of 690 000 home and lei-
sure accidents in the first-aid and emergency de-
partments of the hospitals in The Netherlands. The
number of sports injuries was 206 000, of which
Table V. Distribution of soccer injuries by type of treatment[7)
Soccer
(%)
~ 2 medical treatments 18
1 medical treatment 19
First aid on the pitch, treatment 26
by trainer
Self treatment 16
No treatment 21
Total 100
65
27.4% (56 000) were sustained in soccer. The fol-
lowing treatment regimens were reported for the
soccer injuries: no treatment (4.3%); only one
treatment (31.8%); treatment and referral to a GP
(10.1%); treatment and referral to an outpatient
clinic (45.6%); treatment and referral to a special-
ist (4.4%); inpatient care (3.7%); and, unknown
(0.2%) . There was no difference in the nature of
treatment of soccer injuries compared with the to-
tal number of sports injuries. Sprains, dislocations
and fractures proved to be more serious injuries.
As to the cohort studies, there is a paucity of
information concerning the nature and duration of
treatment. Ekstrand and Gillquist l63] stated that ev-
ery injury which met the admission criteria was
treated by the same orthopaedic surgeon. Exami-
nation under anaesthesia and arthroscopy were
performed on 11 patients (4.3%) with posttrau-
matic swelling of the knee. Four of these patients
(1.6%) underwent an arthrotomy; 2 patients (0.8%)
had an endoscopic meniscectomy. 62% of the in-
juries in the study of Jorgensen l67] were seen by a
physician.
Schmidt-Olsen et al. 169] made a distinction be-
tween 3 levels of injuries : (i) slight injury (only
minor first aid treatment and no advice of reduced
activity); (ii) moderate injury (medical care, but no
hospitalisation and advice of reduced activity); and
severe injury (hospital treatment and advice of re-
duced activity). The incidence of moderate and se-
vere injuries was found to be 9.4 injuries/lOOO
playing hours with a total incidence of 19.1 inju-
ries/lOOO playing hours . Older youth players sus-
tained more severe injuries. The incidence of mod-
erate and severe injuries was 7.4% injuries/lOOO
playing hours for boys and 17.6 injuries/l 000 play-
ing hours for girls with an overall incidence of 16.1
All sports and 29.9 injuries/l 000 playing hours, respectively.
(%) Nielsen and Yde[77j report that 50% of the in-
20
jured soccer players were self treated. 16% of the
18
14
injuries were seen in general practices and 38 inju-
ries (34%) were treated at hospitals. Six knee inju-
21 ries required surgery. In elite senior soccer players,
27 Engstrom et alV 9) noted that of 13 major knee in-
100 juries II (12.9%) required surgical intervention
66 Inklaar

and a long period of rehabilitation . In total, 17 in-
j uries (20.0 %) req uired hospital care . 77 (90%) of
the injuries were treated with physical therapy.
Nonsteroidal anti -inflammatory drugs (NSAIDs)
were pres cribed to 17 (34% ) of the injured players,
mainly for overuse injuries (60 %).
In a study of 2 female soccer teams, Engstrom
et al.[81] found that 28% of injuries required hos pi-
tal facilities, 38 % of injuries were treated with
phy sical therapy and in 14% NSAIDs were pre-
scribed, mainly for overuse injuries.
2,4 Sporting Time Lost
The concept of health in spor ts medicine is
different from tha t customary in standard medi -
cine.f 44] In contrast to nonsporting people, athletes
are considered not fully recovered unless they can
take part in their sport (practice and match). The
length of sporting time lost give s the most precise
indication of the consequences of an injury to an
individuaU 44] In many studie s, classification of
the severity of sports injuries, therefore is based on
the sporting time lost.
Th e NAIRS classifies injuries according to the
length of limitation of athletic participation into
minor (I to 7 days), moderately serious (8 to 2 1
day s) and serious (over 21 day s or permanent dam-
age ) injuries. Thi s classifi cation was used by
McMaster,[58] Resnick,l60] Sullivan et aI.[62] and
Albert. l66] A slightly different cla ssification was
used by Ekstrand and Gillquist,163.641Nielsen and
Yde[77] and Eng strom et aI.!79,81l For both classi-
fications , the resu lts of the different studies are pre-
sented in table VI.
Results are biased by definition of injury, re-
search design and selection of the material. For ex-
ample, in the study of McMaster,L58J a club trainer
kept a daily log of all players of a profe ssional soc-
cer team in the US who complained of or sought
care for injuries. In contrast, in the study of Eng-
strom et al.,L79] the trainers of 3 semi-professional
soccer teams registered all injuries that cau sed ab-
sence from one or more games or practices. The
higher percentage of more serious injuries in the
study of Engstrom et al.[79] at least may be partly
explained by the much higher percentage of over-
use injuries.
Perhaps sporting time lost is not such a valid
criterion for the severity of injuries, since this cri-
terion is highly dependent on the avail ability and
quality of medical care and rehabilitation . The
level of play and sociocultural background proba-
bly are strong confounders here. Good medical care
and rehabilitation may work in opposite way s to-
ward s sporting time lost. They may lengthen the
period of sporting time lost because one has taken
the proper time for rehabilitation. Sportsmen and
sports women tend to return to sports too soon, be-
fore the injury is completely healed and an adequate
rehabilitation has taken place. Otherwise good
medical care may stimulate the healing process
by eliminating harmful factors like haematoma or
oedema. As a result, a quicker return to play is
possible.

Table VI. Sporting time lost by soccerinjuries (%)

Reference 1·7 days 8-21 days > 21 days Total injuries
McMaster5B] 88.3 11.7 11 .7 60
Resnick l60j 65 17.0 17.8 11 2"
Sullivan et aLI62] 50 50 50 34
Albertl6e1 72 24 4 142
< 1 week 1 week-l month > 1 month Totalinjuries
Ekstrand and Glilquistl64] 62 27 11 256
Nielsenand Ydel77j 46 19 35 109
Engstr<lm at aL[79j 27 39 34 85
Engstrom et aLIB'] 49 36 15 78
a Kneeinjuries only.
Incidence and Severity of Soccer Injuries
2.5 Working Time Lost
Like the cost of medical treatment, the amount
of work absenteeism gives an indication of the fi-
nancial consequences of sports injuries to society.[44]
For official statistics, only the work absentee-
ism of employed people, the labour force, is rele-
vant. For example, in the official statistics of the
Industrial Insurance Administration Office and In-
dustrial Insurance Boards many people (including
students, civil servan ts, the military, the disabled,
the unemployed, the self-employed and housewives)
are therefore excluded.P"l
Data of this kind can be used to compare the cost
to society of sports injuries with that of other ac-
tivities involving health risks, such as work and
traffic accidents.l 50] Official national statistics
have the disadvantage that in the differentiation of
activities causing sick leave, only the category
' sports injuries' is included. Separate information
about injuries from individual sports is missing . In
addition, sometimes only sports injuries causing
sick leave of more than 14 days[12] or 28 days[94]
are diagnosed and recorded .
Another approach to gathering information
about sick leave is through the insurance compa-
nies of the soccer associations. Berger-Vachon et
al.[18] calculated the number of sick leave days based
on 3260 out of 6153 soccer accidents reported to
the Rhone-Alpes Soccer Association insurance
company, where the number of sick leave days was
indicated. A total number of 68 800 sick leave days
were reported during the 1980-1981 season. Ex-
trapolation to the whole of France gives an equiv-
alent of 2000 years of sick leave for that season .
The average amount of sick leave showed the high-
est value for tendon ruptures (41.6 days), followed
by fractures (37.0 days) and sprains (20.8 days).
This information most likely is biased by response
and representativeness of the study population.
In a prospective I-year study in a rural munici-
pality in Sweden, de Loes[39] recorded a total num-
ber of 1416compensated work-related sick leave
days for 68 injuries, i.e. a mean duration of 20.8
sick leave days for each injury. For all sports, the
average length of sick leave was found to be 21.5
67
days. The arithmetic mean here is an inadequate
indicator of a central tendency in the distribution
of data when the distribution is skewed . Here, the
distribution is skewed to the right, where the arith-
metic mean clearly overestimates the central ten-
dency. In such cases the use of mode or median
values is indicated.
Hey et al. [4 J] prospectively studied 715 patients
with soccer injuries which were registered and
treated in the emergency department of a Danish
hospital during 1 year. 31 % had been absent from
work, but only 8% of the patients had a loss of
income because of their injury. The average ab-
sence from work was 5 days per person. There was
a significant correlation (r = 0.24, P < 0.001) be-
tween the estimation of the severity of the lesion
according to the Abbreviate Injury Scale f95] and
the length of absence from work.
In the cohort studies, work absenteeism is
hardly used as a parameter for the severity of soc-
cer injuries. Only Kristiansenlv'l reports that
84.2% of the soccer injuries in young schoolboys
did not lead to missed days at school, 14.0% to only
1day and 1.8% to 2 or more days missed at school.
2.6 Permanent Damage
The majority of sports injuries heal without per-
manent disability. Serious injuries can, however,
cause permanent physical damage, disability or
death. Permanent physical damage may result in
persistent symptoms from a past injury. If residual
symptoms are slight, a soccer player is often able
to continue playing at the desired or former level
of play. More severe symptoms sometimes force
players to lower the level of play, or even quit soc-
cer and choose another less demanding sport or
give up sport altogether.
Ekstrand and Gillquist[53] examined 180 ama-
teur soccer players for persistent symptoms from
past injuries . 26 players (14.4%) had persistent
knee instability resulting from past injury, 21 play-
ers showing anteromedial rotatory instability and
2 players straight posterior instability. 31 players
(17.2%) had persistent symptoms from a previous
68
ankle sprain. 52 players (28.9 %) had a clinical in-
stability from a previous ankle sprain.
Tropp et ai.l 961 examined 444 senior amateur
soccer players for functional and mechanical insta-
bility of the ankle. There was a history offunctional
instability in 159 of 888 ankl e joints (18 %). A pos-
itive anterior drawer sign was found in 118 ankle
joints (13%). A combined functional and mechan-
ical instability was found in 66 ankle joints (7%).
Nielsen and Yde l771 report that with follow-up
12 months after the sea son in which injury oc-
curred, 28% of the injur ed players still had com-
plaints. Knee injuries and strains manifested the
highest rate s of complaints. Five players had not
returned to soccer as a consequence of their inju-
ries , but all other injured players were active de-
spite their injury. Engstrom et al.,1791at a follow-up
9 to 18.5 JDonths after the injury, found that 4 of 12
players with major knee injuries had returned to
play at an elite level. The other players either had
been transferred to lower divisions or were still in
rehabilitation.
Brynhildsen et al.[561 examined 150 female soc-
cer players for persistent symptoms from past in-
juries. Mechanical instability was shown in 20
player s (13 .3%) with previous ankle sprains. 14
players (9.3 %) with previous ankle sprains had
persistent symptoms. Players with mechanical in-
stability were more prone to persistent symptoms
(p < 0.05) . II players (7.3 %) with previous knee
sprains had per sistent symptoms. 4 players had
persi stent instability (positive Lachman test) sug-
gesting an old anterior cruciate ligament (ACL)
rupture. None of the players showed any me-
dial/lateral instability or positive pivot shift. Al-
most 50 % of the players who had suffered shin
splints or had a history of iliotibial tract tendinitis
still had symptoms. None of the players with pre-
vious strains had persistent symptoms. Four out of
five players with previous dislocations of the pa-
tella still had persi stent symptoms.
Finally, the health risk of soccer can be esti-
mated by comparing former soccer players with
matched controls who never played soccer and/or
with still active soccer players. The results of case
lnklaar
control studies of former soccer players suggest
that long term expo sure to soccer seems to be a risk
factor for developing osteoarthro sis of the hip,197-99]
the kneeI97.100] and the ankle.l 1OOj Adjusted rela-
tive risks of developing coxarthrosis for former play-
ers with different intensities of exposure suggest a
dose-response relation.!99] Elite soccer players ap-
parently run an increased risk of developing cox-
arthrosis,1981 osteoarthrosis of the knee, especially
after a meniscectomy I100.101] and in the presence
of pathological ligamentou s instability,l 100] and ar-
throsis of the ankle 11OO] compared with amateur soc-
cer players or nonsoccer-playing control individuals.
Tysvaer[ 1021 included 69 active soccer players
and 37 former players of the Norwegian national
team, both groups with matched control groups of
59 and 37 people, respectively, in a study of per-
sistent symptoms and neurological and neu-
ropsychological changes due to repetitive minor
head and neck injuries. 3% of the active players and
30% of the former players complained of persistent
symptoms (headache, dizziness, irritability, im-
paired memory and neck pain). 35% of the active
and 32 % of the former players had from slightly
abnormal to abnormal electroencephalogram (EEG)
changes compared with 13 and II % of matched
controls respectively. There were fewer definitely
abnormal EEG changes among typical ball headers
(10 %) than among nonhe aders (27 %). One-third of
the former soccer players were found to have cen-
tral cerebral atrophy on computer tomography, and
81% to have from mild to severe neuropsychologi-
cal impairment compared with 40% with only mild
impairment in the control group. Radiological ex-
amination of the cervical spine revealed a signifi-
cantly higher incidence and degree of degenerative
changes than in the matched control group. The
results were con sidered as mostly minor damage to
brain and cervical spine due to repetitive minor
head and neck injuries in soccer.
In contrast, Haglund and Eriksson 1I03] found no
signs of chronic brain damage in 25 soccer players
selected from the first and second division teams. All
players underwent medical examination, neurolog-
ical examination, neuroradiological examination,
Incidence and Severity of Soccer Injuries
neurophysiological examination (EEG) and neu-
ropsychological examination. An explanation of
the different results in the studies of Tysvaer l1021
and of Haglund and Erik ssonl 103] could be the dif-
ferent style of play and use of heading by the play-
ers from different countries.
2.7 Costsof Soccer Injuries
Cost-benefit analysis is useful in the study of
the economic consequences of certain activities to
the community and in the study of the effect of
preventive measures. A cost analysis must identify
the sports (groups) which are most expensive in to
determine targets for intervention. In the develop-
ment of cost models, general agreement about the
standardisation of the model is necessary.l 1041
A general classification of the economic costs
of sports injuries was proposed by Tolpin et al.l 1051
Economic costs are divided into direct costs (i.e.
costs of medical treatment) and indirect costs [i.e.
expenditure incurred in connection with the loss of
productivity due to increased morbidity (work ab-
senteeism or permanent incapacity for work) and
mortality levels] . Social costs can be classified as
quantifiable and not quantifiable.f 44 ] Quantifiable
costs include insurance and legal expenses. Un-
quantifiable costs are the harmful effects of a
sports injury to the psychosocial life ofthe individ-
ual or their family (e.g. economic dependence, loss
of social status or social isolation).
For example, based on existing cost models in
the US (National Electronic Injury Surveillance
System) and Great Britain (Home Accident Sur-
veillance System), the Dutch Consumer Safety In-
stitute elaborated a cost model including the cost
of medical treatment (admission to hospital, inpa-
tient treatment by a specialist, admission to a nurs-
ing home, admission to a rehabilitation centre, out-
patient treatment in a hospital, day treatment in a
rehabilitation centre, treatment by a GP, treatment
by a dentist, physiotherapy, home help and district
nursing service), transport by ambulance, work
absenteeism and permanent incapacity for work.
However, an adequate injury registration system
remains essential to any assessment of the total
69
costs associated with sports injuries. This system
must be reliable and continuous.
Based on the cost model of the Dutch Consumer
Safety Institute and the data of the national popula-
tion survey of accidents in The Netherlands,l7·106]
the direct and indirect costs associated with medi-
cally treated sports injuries have been estimated to
be up to at least $US225 million in 1987.11041 An
underestimation is plausible because of underre-
porting of chronic overuse injuries. Providing that
soccer injuries, which comprise 29% of all sports
injuries, are not more serious than the injuries of
other sports , the direct and indirect costs of soccer
injuries can be estimated to be at least $US65 mil-
lion in 1987.
Most of the other studies dealing with the costs
of soccer injuries were confined to the direct costs .
Roaas and Nilssonll-l report that over the period
1970 to 1974, 3616 injuries were recorded and a total
of $US270 000 was paid out by the insurance com-
pany of the Norwegian Football Association. How-
ever, this type of insurance does not compensate for
the financial consequences of work absenteeism.
Pritchett[ 161 examined the files of the largest
single insurance company of secondary school stu-
dents in 6 western states in the US. The average
cost of 436 high school soccer injuries reported for
1976 and 1977 was $US127.29. Knee injuries were
the most costly, accounting for 11.7% of all inju-
ries and 28.2% of all medical costs . The internally
damaged knee accounted for 17% of all medical
expense, more than any other type of injury. Com-
pared with American football, soccer is much less
taxing on medical resources (less than 16% of those
for American football) and was therefore consid-
ered to be comparatively safe.
Ekstrand[107] estimated the cost of medical care
and sick leave for a Division IV team in Sweden in
1981 at about $US420 000. Berger-Vachon et a1.[18]
report that the direct and indirect costs of the inju-
ries sustained by soccer players from the Rhone-
Alpes Soccer Association 1980-1981 competition
was approximately FFr8 750 000 ($USl 625000).
The estimated costs of soccer injuries for France
would have been FFrIOO 000 000 ($US18 600 000).
70
For all sports injuries, the mean cost per patient
for medical treatment was $US209 ± 348. The
mean cost per day of sick leave for 68 patients with
soccer injurie s entitled to sick leave compensation
was $US492 ± 863 compared with $US443 ± 707
for all sport s combined. For medical care and sick
leave, concu ssion s, fractures and dislocations were
the most co stly inju rie s (mean costs $US 1173,
$US 1193 and $U S 1128, respectively). With re-
spect to sprains, the sprain of the knee was the most
expensive injury with a mean cost of $US553. Soc-
cer and handball had the highe st absolute costs, but
as to mean costs per patient of medical treatment
soccer ranked only sixth and for costs per patient
of sick leave compensation, soccer ranked fifth of
all sports .
The se figure s are of limited value, as the vari-
ance is greater than the actual mean . Most probably
the skew is highl y positive , meaning that the costs
of the vast majority of the injuries are limited. Only
a few sports injuri es are sufficiently serious that
exten sive and costly medical treatment and a long
period of sick leave are required. Median values are
therefore more meaningful , and are indicated.
H¢y,[4I J in a study of 715 patients with soccer
injuri es, defined financial loss to the individual as
the difference between usual wages and the finan-
cial aid granted from the social security system or
insuran ce. A total of 41 patients (8%) had a loss in
income. Of these, 40 % lost up to $US250, 40 % lost
between $US250 and $US750, 7% lost between
$US750 and $US1250 and 12% lost more than
$US 1250. Because of the high number of school
students amongst the injured player s and the wel-
fare sys tem in Denmark, which provide s free hos-
pital treatment and complete or partial compensa-
tion for finan cial losses durin g sick leave, no
correlation wa s found between the da ys absent
from work and the indi vidual loss of income . How-
ever, most studies using record s of insurance com-
panies or carried out in a hospital are biased by
selection and are less valid . Also, data from studies
on soccer injury costs need to be compared with
data from other sports. Differences in the calcu-
lated cost s of medic al care and sick leave between
lnklaar
soccer injury studies of different countries may be
partly expl ained by differences in the organisation
of the healthcare and social security systems in the
respective countries.
Finally, a cost-benefit analysis for sport (e.g. soc-
cer) is incomplete if the con sequences of sports
injuries ar e anal ysed without mentionin g the
benefit of sports for preventing disease.l 391A cost-
benefit analysi s of the positive and negat ive effects
of sporting activities is needed.l 1081 According to
Soren sen and Sonne-Holm,l109J the adverse socio-
economic effects of sports injuries are outw eighed
by the positive effect of sporting activities. Indeed,
van Puffelen et al. lIlO] calculated an over all posi-
tive balanc e of $US86 million a year for The Neth-
erlands due to sports participation. Their calcula-
tion involved the costs of medical care and work
absenteei sm. They showed a positive balanc e with
regard to GP consultation, inpatient treatment and
a negative balance for consultation of medical spe-
cialists and working time lost. With work time lost,
only a positive effect was found in the 35 to 45
years age group. These results need confirmation
from other studies in which a differentiation is
made in type of sport.
3. Conclusions
Stud ies of the incidence and severity of soccer
injuries have produced a variety of (sometimes con-
flictin g) result s. This outcom e may be explained by
differences in the definition of injury, the method
of data colle ction , and by selection criteria (age,
gender, level of pla y and socioc ultural back-
ground) being recogni sed. These differences have
to be accounted for when comparing different stud-
ies. It seems almost impossibl e to transfer the re-
sults of a study of injuri es in a subgroup to the total
soccer popul ation.
A general conclusion is that the incidence of in-
jury depends on the population being studied. High
risk group s have been identified with respect to
age, gender (at least in youth players) and level of
competition. Game s produce a higher risk of injury
than practice , even when corrected for exposure
time. Further epidemiological study of the effect of
Incidence and Severity of Soccer Injuries
age, gender and level of play is required to support
the results of the studies mentioned above.
It is concluded that in countries where soccer is
a very popular sport, soccer may tax the healthcare
and social security systems considerably. This may
warrant the development of an effective prevention
strategy in those countries. For this purpose iden-
tification of high risk groups with respect to the inci-
dence and severity of soccer injuries is necessary.
References
I. FIFA. Statistics on the 186 affiliated national associations of
FIFA . Zurich: FIFA. 1992
2. UEFA bulletin, Bern. 1988
3. Ekblom B. Applied physiology of soccer. Sports Med 1986; 3:
50-60
4. Tysvaer A. Storli O. Association football injuries to the brain .
preliminary report. Br J Sports Med 1981; 15 (3): 163-6
5. Bach FJG. Beijer HJM. Bol E. et al. Injuries in high risk per-
sons and high risk sports. Am J Sports Med 1991 : 19: 124-30
6. Rogmans WHJ. Ernst en omvang van ongevallen in de
pri vesfeer, Amsterdam: Consumer Safety Institute. 1982
7. van Galen W. Diederiks J Sportblessures, breed uitgemeten.
Haarlem: de Vrieseborch, 1990
8. Inklaar H. Soccer injuries. II : aetiology and prevention. Sports
Med. In press
9 . Mosterd WL. Medische begeleiding in de sport. Amsterdam:
Wetenschappelijke Uitgeverij BV, 1973
10. Groh H, Groh P. Sportverletzungen und Sportschaden. Munich:
Lutpold Werk, 1975
11. Biener K, Fasler S. Sportunfalle, Epidemiologie und Pra-
vention. Berne: Hans Huber Verlag, 1978
12. Roaas A, Nilsson S. Major injuries in Norwegian football . Br J
Sports Med 1979; 13: 3-5
13. Franke A, Franke K. Epidemiologie von Unfallen und
Fehlbelastungsfolgen beim Sport. Medizin Sport 1980; 6:
184-9
14. Minarovjech V. Knowledge of anti-injury in the league football
soccer in Czechoslovakia. In: Vecchiet L, editor. Proceedings
l st International Congress on Sports Medicine Applied to
Football. Vol II. Rome: D Guanella, 1980: 871-8
IS. Napravnik C. Prevention of accidents in football. In: Vecchiet
K. editor. Proceedings 1st International Congress on Sports
Medicine Applied to Football. Vol II. Rome: D Guanella,
1980; 879-82
16. Pritchett Jw. Cost of high school soccer injuries. Am J Sports
Med 1981; 9 : 64-6
17. Sandelin J, Santavirta S. Kiviluoto O. Acute soccer injuries in
Finland in 1980. Br J Sports Med 1985 ; 19 (I): 30-3
18. Berger-Vachon C. Gabard G, Moyen B. Soccer accidents in the
French Rhone-Alpes Soccer Association. Sports Med 1986 ;
3: 69-77
19. Biener K. Caduff R. Augenverletzungen im Sport. Dtsch Zeit-
schr Sportsmed 1987; 38 (3): 118-22
20. Nysether S. Dental injuries among Norwegian soccer players .
Community Dent Oral Epidemiol 1987; 15: 141-3
21. Wehmeyer K. Initial results of an epidemiologic registration
system for club sports accidents. In: van der Togt CR. Kemper
ABA. Koornneef M, editors. Proceedings 3rd Meeting Coun-
71
cil of Europe. Oosterbeek: National Institute for Sports
Health Care, 1988
22. Inklaar H. Sportletsels in de huisartspraktijk. Huisarts Weten-
schap 1986; 29 : 265-8
23. Boersma-SHitter A, Broekman A, Lagro HAHM. et al. Sport.
een riskante zaak ? Geneesk Sport 1979; 16: 41-9
24. Chambers RB. Orthopaedic injuries in athletes (ages 6 to 17).
Am J Sports Med 1979 ; 7 : 195-7
25 . Sonne-Holm S. Sorensen CH. Risk factors with acute sports
injuries . Br J Sports Med 1980; 14: 22-4
26 . Sandelin J. Kiviluoto O. Santavirta S. et al. Outcome of sports
injuries treated in a casualty department. Br J Sports Med
1985; 19: 103-6
27. Burke MJ , Sanitato JJ, Yinger PF, et al. Soccerball induced eye
injuries. JAMA 1983 ; 249: 2682-5
28. Steinbrlick K. Cotta H. Epidemiologie von Sportverletzungen.
Dtsch Zeitschr Sportmed 1983; 6: 175-84
29. Devereaux MD, Lachmann SM . Athletes attending a sports in-
jury clinic - a review . Br J Sports Med 1983; 17 (4) : 137-42
30. Klasen HJ. Letsels ten gevolge van ongevallen bij voetballers.
T Soc Geneesk, 1984
31. Maehlum S. Daljord OA. Acute sports injuries in Oslo: a one
year study. Br J Sports Med 1984; 18 (3): 181-5
32. von Pfister A. Pforringer W. Rosemeyer B. Epidemiologie von
Sportverletzungen. Dtsch Zeitschr Sportmed 1985; 10: 291-4
33. DeHaven K, Lintner DM . Athletic injuries: comparison by age,
sport and gender. Am J Sports Med 1986; 14: 218-24
34. Kujala UM. Kvist M, Osterman K. Knee injuries in athletes,
review of exertion injuries and retrospective study of outpa-
tient sports clinic material. Sports Med 1986; 3: 447-60
35. Kannus P, Aho H. Jarvinen M. et al. Computerized recording of
visits to an outpatient sports clinic. Am J Sports Med 1987;
IS: 79-85
36. Sadat-Ali M, Sankaran-Kutty M. Soccer injuries in Saudi Ara-
bia . Am J Sports Med 1987; 15: 500-2
37. Kurock W, Sennerich Th . Beitrag zur Epidemiologie der
Sportverletzungen. Dtsch Zeitschr Sportsmed 1988; 15 (5):
500-2
38. Vuori I. Sports and exercise injuries and their prevention in
Finland. In: van der Togt CR. Kemper ABA. Koornneef M.
editors. Procedings 3rd Meeting Council of Europe.
Oosterbeek: National Institute for Sports Health Care, 1988 :
135-45
39 . de Loes M. Medical treatment and costs of sports related inju-
ries in a total population . Int J Sports Med 1990; 11: 66-72
40 . Bach FJG . Beijer HJM, Bol E. et al. Blessures op sport-
medische adviescentra en sportmcdische afdelingen. Geneesk
Sport 1990; 23 (I) : 8-12
41. H0y K. Lindblad BE. Juhl Terkelsen CJ , ct al. European soccer
injuries. Am J Sports Med 1992; 20: 318-22
42. Tenvergert EM. Ten Duis HJ, Klasen HJ. Trends in sports inju-
ries , 1982- I988. An in depth study on four types of sport: J
Sports Med Physical Fitness 1992; 32 (2): 214-20
43. Home and Leisure Accident Survei11ance System (PORS) on-
going registration since 1983. Amsterdam: Consumer Safety
Institute, 1990
44. van Mechelen W. Hlobil H, Kemper HCG. Incidence. severity.
aetiology and prevention of sports injuries. Sports Med 1992;
14: 82-99
45 . Keller CS. Noyes FR. Buncher CR. The medical aspects of
soccer injury epidemiology. Am J Sports Med 1987; 15: 230-7
46. Noyes FR, Lindenfeld Th, Marshall MY. What determines an
athletic injury (definition)? Who determines an injury (occur-
rence)? Am J Sports Med 1988; 15 Suppl.: 65-8
72
47. Damron CF. Injur y surveillance systems for sports. In: Yinger
PE Hoerner EF, editors. Sports injurie s, the unthwarted epi-
demic. Littleton: John Wright PSG Inc, 1981
48. van Vulpen AV. Sports for all, sports injuries and their preven-
tion, scientific report. Oosterbeek : Council of Europe, Na-
tionallnstitute for Sports Health Care, 1989
49. Kristiansen B. Associati on football injuries in schoo lboys.
Scand J Sports Sci 1983; 5 (I ): 1-2
50. Kranenborg N. Sportbeoefe ning en blessures. T Soc Geneesk
1982; 60 (9): 224-7
5 I. Walter SD. Sutton JR, Mcinto sh JM, et al. The aetiology of
sports injuries. A review of methodologies. Sport s Med 1985 ;
2: 47-58
52. Masseij J, Gonzales J. Optimum recall periods for estimatin g
accidental injuri es in the National Health Interview. Proceed -
ings of the Socia l Statistics Section, American Statisitical As-
sociation, 1976: 584-8
53. Ekstrand J, Gillquist 1. The frequency of muscle tightness and
injuri es in soccer players. Am J Sports Med 1982; 10: 75-8
54. Hoff GL , Martin ThA. Outd oor and indoor soccer: injuries
among youth players. Am J Sports Med 1986; 14: 23 1-3
55. Bernkl au S, Wollein W. Medizinische Aspekte des Damen-
fussballspiels. Osler J Sports Med 1984; 14 (4): 17-20
56. Brynhildsen J, Ekstrand J. Jeppson A, et al. Previous injuries
and persisting symptoms in female soccer players. Int J Sports
Med 1990; 11: 489-92
57. Berbig R. Hiener K. Sportunfalle bei Fussba lltorhu ettern.
Schweiz Zeitschr Sports Med 1983; 3 1: 73-9
58. McMa ster W. Injuries in soccer. Am J Sports Med 1978; 6:
354-7
59. Nilsson S, Roaas A. Soccer injuries in adolescents. Am J Sports
Med 1978; 6: 358-6 1
60. Resnick EJ. Etiology and pathogenesis of football knee injuries .
In: Vecchiet L, edito r. Proceedings l sI International Congress
on Sports Medicine Applied to Football. Vol II. Rome: D
Guanella, 1980: 481-9
61. Pontano O. Gambacorta G, Colozzi A. et al. Reports on acci-
dent s of foo tball players carried out dur ing the seasons
1976/1977 and 197711 978. In: Vecchiet L, editor. Proceeding s
1st Intern ational Congress on Sports Medicine Applied to
Footba ll. Rome: D Guanella, 1980: 861-6
62. Sullivan JA, Gross RH, Grana WA, et al. Evaluation of injuries
in youth soccer. Am J Sports Med 1980; 8: 325-7
63. Ekstrand J, Gillquist J. Soccer injuries and their mechanisms: a
prospective study. Med Sci Sports Exerc 1983; 15 (3): 267-70
64. Ekstrand J. Gillqui st J. The avoidability of soccer injuries . Int J
Sports Med 1983; 4: 124-8
65. Ekstrand J. Gillqu ist J. Moller M, et al. Incidence of soccer
injuries and their relation to training and team success . Am J
Sports Med 1983; I I: 63-7
66. Albert M. Descriptive three year data study of outdoor and in-
door professional soccer injuries. Athletic Training 1983; 18:
218-20
67. Jorgensen U. Epidemiology of injuries in typical Scandinavian
team sports. Br J Sports Med 1984; 18 (2): 59-63
68. McCarroll J, Meaney C, Sieber JM. Profile of youth soccer
injuries. Physician Sportsrncd 1984; 12 (2): 113-7
69. Schmidt- Olsen S, Biinemann LKH, Lade V, et al. Soccer inju-
ries of youth. Int J Sports Med 1985; J9 (3): 161-4
70. Maehlum S, Dahl E. Daljord OA. Frequency of injuries in a
youth soccer tournament. Physician Sportsmed 1986; 14 (7):
73-9
lnklaar
71. Eriksson LT, Jorfeldt L, Ekstrand J Overu se and distorsion soc-
cer injuries related to the players estimated maximal aerobic
work capacity. Int J Sports Med 1986; 7: 214-6
72. Lysens RJJ. Epidemiol ogical study of soccer injuries in the 18
teams of the first national division of the Royal Belgium Soc-
cer Association (RBSA) durin g the seaso n 1980-1981.ln: van
der Togt CR, Kemper ABA. Koornneef M. editors. Proceed-
ings 2nd Meeting Council of Europe: sports injuries and their
prevention. Oosterbeek: National Institute for Sports Health
Care, 1987: 16-7
73. Poulmedi s P. Muscular imbalance and strains in soccer. In: van
der Togt CR , Kemper ABA, editors. Proceedings 3rd Meeting
Council of Europ e: sports injuri es and their prevention.
Oosterbeek : National Institute for Sports Health Care, 1988:
53-7
74. Jorgensen U, Sorense n J. Free substitution in soccer: a prospec-
tive study. In: van derTogt CR, Kemper ABA, Koornneef M,
editors. Proceed ings 3rd Meeting Council of Europe . Sports
injuries and their prevention. Oosterbeek: National Institute
for Sport s Health Care. 1988: 155-8
75. Backous DD. Friedl KE, Smith NJ, et al. Soccer injuri es and
their relation to physical maturity. Am J Dis Child 1988; 142:
839-42
76. Moller-Nielsen J. Hamm ar M. Women' s soccer inj uries in rela-
tion 10 the mentrual cycle and ora l contraceptive use. Med Sci
Sports Exerc 1989; 2 1 (2): 126-9
77. Nielsen AB, Yde J. Epidemiology and traumatology of inj uries
in socce r. Am J Sports Med 1989; 17: 803-7
78. Ekstrand J, Tropp H. Incidence of ankle sprains in soccer. Foot
Ankle 1990; II (I): 41-3
79. Engstrom B, Forssblad M. Johansson C. et al. Does a major knee
injury definitely sideline an elite soccer player ? Am J Sport s
Med 1990; 18: 101-5
80. Schm idt-Olsen S. Jorgensen U, Kaalund S. et al. Injuries among
young soccer players. Am J Sports Med 1991: 19: 273-5
81. Engstrom B. Johansson C, Tornkv ist H. Soccer injuri es among
elite female players. Am J Sports Med 1991; 19: 273-5
82. Winkler W. A new approach 10 the video analysis of tactical
aspects of soccer. In: Reilly T. Lees A, Davids K, et al., editors.
Proceedin gs of the Ist World Congress of Science and Foot-
ball. London: E & FN Spo n, 1988: 368-73
83. Hoi E, Schmikli SL, Backx FJG, et al. Sportblessures onder de
knie. Programmerin g van toekomstig onderzoek. Oosterbeek:
Nationaal Instituut voor de Sportgezondheidszorg. 1991
84. Taimela S, Kujala UM, Osterman K. Intrinsic risk factors and
athletic injuries . Sports Med 1990; 9: 205- 15
85. Fletcher RH, Fletcher SW. Wagner EH. Clinical epidemiology.
the essentials. London: Williams and Wilkins, 1992
86. Lindenfeld TN , Noyes FR. Marshall MR. Comparents of injury
reporting systems. Am J Sports Med 1988; 16 Suppl. I: 69-80
87. Zar iczny B, Shattu ck LJM , Mast TA, et al. Sp orts-related
injuries in schoo l-age d children. Am J Sp orts Med 1980 ; 8:
3 18-24
88. Ekstrand J, GilIquist J, Liljedahl SO. Prevention of soccer inju-
ries. Supervision by doctor and physiotherapist. Am J Sports
Med 1983; II : 116-20
89. Backx FJG, Erich WBM. Kemper ABA, et al. Sports injurie s in
school aged children. An epidemiologic study. Am J Sports
Med 1989; 17: 234-9
90. Thorndik e A. Frequency and nature of sports injuries. Am J Surg
1959; 98: 316-24
9 1. Standard Nomenclature of Athletic Injuries. Chicago : American
Medical Association, 1966
Incidence and Severity of Soccer Injur ies
92. Williams JGP. Aetiological classification of injuries in sports-
men. Br J Sports Med 1971; 5: 228-32
93. Lysens RH. Ostyn MS. Prolegomena bij de preventie van
sportletsels, Hermes 1984; 17: 85-94
94. Vermeer JP.Sport en sociale verzekering. T Soc Geneesk 1982;
60: 222-3
95. Anonymous. Rating the severity of tissue damage: 1. The ab-
breviated scale. JAMA 1971; 215: 277-80
96. Tropp M. Askling C. Gillquist J. Prevention of ankle sprains.
Am J Sports Med 1985; 13: 259-62
97. Kliinder KB. Rud B. Hansen J. Osteoarthritis of the hip and
knee joint in retired football players. Acta Orthop Scand
1980; 51: 925-7
98. Lindberg H. Roos II. Gardsell P. Prevalence of coxarthrosis in
formersoccer players. Acta Orthop Scand 1993; 64 (2): 165-7
99. Vingard E. Alfredsson L. Goldie I. et al. Sports and osteoarthro-
sis of the hip. Anepidemiologicstudy.AmJ Sports Med 1993;
21: 195-200
100. Brouwer PJ, Geesink RGT, Prompers LAJL. et aJ. Klachten en
afwijkingen aan knieen en enkels bij ex-profvoetballers uit
1956. Geneesk Sport 1981; 18: 694-7
10I. Muckle DS. Factors affecting the prognosis of meniscectomy
in soccer players. Br J Sports Med 1983; 17 (2): 88-90
102: Tysvacr AT. Head and neck injuries in soccer. Impact of minor
trauma. Sports Med 1992; 14 (3): 200-13
73
103. Haglund Y. Eriksson E. Does amateur boxing lead to chronic
brain damage? A review of some recent investigations. Am J
Sports Med 1993; 21: 97- 109
104. den Toom PJ. Schuurman MIM. Een kostenmodel voor
berekening van kosten van ongevallen in de privesfeer, Am-
sterdam: Consumer Safety Institute. 1988
105. Tolpin HG. Bentkover 10 . Economics of sports injuries. In:
Yinger PI', Hoerner EF, editors. Sports injuries. the un-
thwarted epidemic. Bristol: John Wright. 1981
106. van Montfoort GLM, van Galen WChC. Harris MA.
Ongevallen in Nederland. Amsterdam: Consumer Safety In-
stitute. 1988
107. Ekstrand J. Soccer injuries and their prevention. Linkiiping
University. medical dissertation no. 130, Linkoping, 1982
108. Shephard RJ. The impact of exercise upon medical costs. Sports
Med 1985: 2: 133-43
109. Sorensen CH, Sonne-Holm S. Social costs of sports injuries. Br
J Sports Mcd 1980: 14: 24-5
110. van Puffelen F. Reyman JON, Velthuysen JW. Sport en
gezondheid, economisch bezien. Amsterdam: SEO. 1989
Correspondence and reprints: Dr Han lnklaar, Sportsph ysi-
cian, Deparlment of Medical Physiology and Sports Medi-
cine, Utrecht University, PO Box 80043, 3508 TA Utrecht,
The Netherlands.