Increase in ACL and PCL injuries after implementation of a new professional football league

[Complex knee injuries in football : Management from injury to return to competition]

BACKGROUND

Knee joint injuries are a regular and serious injury in football, often resulting in a long period of absence for players and are, therefore, a significant disadvantage for clubs. The various structures of the knee joint, such as ligaments, meniscus or cartilage, are exposed to the risk of injury due to different sport-specific situations in football and require different and specific therapeutic approaches for their adequate healing.

TREATMENT

Both surgical and conservative treatment measures have been well investigated scientifically, especially for knee joint injuries in football, so that a successful and sustainable return to play on field is highly possible. Only in professional football is there a deviation from the usual standard of treatment in special situations in order to meet the demands and goals of professional footballers. In order to do address different subpopulations in football in the various injury types, both in treatment and in the return to play decision and, thus, sustainable secondary prevention, in addition to knowledge of scientific evidence on knee joint injuries, basic experience in the sport in which the patients with knee joint injuries are active is also useful.

Epidemiology of Injury and Illness in North American Professional Men's Soccer: Comparing COVID-19 Lockdown With Previous Seasons

BACKGROUND

After COVID-19 lockdown, studies across Europe and Asia examined its effect on professional soccer injury rates and severity; however, COVID-19 lockdown influence on injuries in United States men's professional soccer has not been evaluated.

HYPOTHESIS

Injury and illness rates during the 2020 season were higher than the previous 2 seasons.

STUDY DESIGN

Retrospective observational cohort study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Medical staff from participating Major League Soccer (MLS) clubs entered injuries and athletic exposures during the study period into a league-wide electronic medical record system. Injury rate and severity were analyzed to examine differentials between the 2020 COVID season and historical controls.

RESULTS

The injury incidence rate per 1000 hours in 2020 was 10.8, ie, higher than 2018 (5.4) and 2019 (5.0) (P < 0.05). Training injury incidence rate increased in 2020 (8.9) compared with 2018 (2.5) and 2019 (2.6) (P < 0.05), whereas match injury incidence decreased in 2020 (18.3) compared with 2018 (24.0) and 2019 (22.7) (P < 0.05). Incidence rates of lower extremity muscle injuries (6.04), anterior cruciate ligament (ACL) injuries (0.17), and concussions (0.49) were also higher in 2020 compared with 2018 (2.5, 0.07, 0.27) and 2019 (2.36, 0.05, 0.22) (P < 0.05). More injured players in 2020 missed >90 days (17.7%) than in 2018 (10.2%) and 2019 (10.1%) (P < 0.05). Incidence of all non-COVID-19 illness was higher in 2020 (3.93) than 2018 (1.53) and 2019 (1.32) (P < 0.05).

CONCLUSIONS

During 2020, there were significant increases in incidence rates of overall injuries, training injuries, lower extremity muscular injuries, ACL injuries, concussions, and non-COVID illness, along with a higher percentage of players missing >90 days compared with the 2 previous seasons.

CLINICAL RELEVANCE

These results may help clarify the effects of future MLS inseason work stoppages and periods of restricted training.

The larger patellar tilt angle and lower intercondylar notch angle might increase posterior cruciate ligament injury risk: a retrospective comparative study

BACKGROUND

Posterior cruciate ligament (PCL) injuries are common ligament injuries of the knee, and previous studies often focused on the associations between the morphology of the knee and PCL injuries. Studies on the correlation between PCL injuries and patellofemoral alignment are limited.

METHODS

This retrospective study included 92 patients with PCL injured and 92 patients with PCL intact. Measurement parameters were compared between the two groups, including patellar tilt angle, congruence angle, patellar height, hip-knee-ankle angle, lateral trochlear inclination, femoral condyle ratio, bicondylar width, intercondylar notch width and index, notch angle, trochlear facet asymmetry, and trochlear sulcus depth and angle. Independent risk factors associated with PCL injuries were identified by logistic regression analyses.

RESULTS

In the PCL injured group, the patellar tilt angle was significantly larger (13.19 ± 5.90° vs. 10.02 ± 4.95°, P = 0.04); the intercondylar notch angle was significantly lower (60.97 ± 7.83° vs. 67.01 ± 6.00°, P = 0.004); the medial and lateral femoral condyle ratio were significantly larger (0.63 ± 0.64 vs. 0.60 ± 0.56, P = 0.031; 0.65 ± 0.60 vs. 0.58 ± 0.53, P = 0.005) than in the PCL intact group. There were 11 patients with patellar dislocation in the PCL injured group, accounting for 12%. In these patients, the patellar height was higher (1.39 ± 0.17 vs. 1.09 ± 0.25, P = 0.009); the trochlear sulcus angle was larger (157.70 ± 8.7° vs. 141.80 ± 8.78°, P < 0.001); and the trochlear sulcus depth was shallower (3.10 ± 1.20mm vs. 5.11 ± 1.48mm, P = 0.003) than those in the patients without patellar dislocation. Multivariate analyses showed that patellar tilt angle (each increase 1 degree, OR = 1.14) and intercondylar notch angle (each increase 1 degree, OR = 0.90) were independent risk factors for PCL injuries.

CONCLUSION

The patients with PCL injuries had larger patellar tilt angles, lower intercondylar notch angles, and longer posterior femoral condyles than patients with PCL intact. The larger patellar tilt angle and lower intercondylar notch angle might be risk factors for PCL injuries.

Utility of SpeedCourt System: A Novel Study of 100 Professional Footballers at FIFA Medical Centre of Excellence Dubai UAE

Purpose

The SpeedCourt system has been confirmed as an effective and dependable tool for evaluating multi-directional change-of-direction (COD) maneuvers. It has also been employed in the rehabilitation process following Anterior Cruciate Ligament (ACL) injuries and for multi-directional training purposes. This study investigated by means of the SpeedCourt system determines 1) whether there is any difference in COD parameters and countermovement jumps (CMJ) between United Arab Emirates (UAE) and non-UAE professional footballers 2) whether there is any difference between the two lower limbs during change-of-direction manoeuvres.

Methodology

This analysis included 100 professional football players from UAE or Non-UAE football clubs who were tested at FIFA Medical Centre of Excellence. With the help of Speedcourt system, 6-s tapping, countermovement jump (CMJ) and chase 15-s tests were performed. Comparison was done between UAE and non-UAE footballers and also between the dominant and non-dominant sides.

Results

Out of the 100 players, 83 players were right foot dominant. Apart from the countermovement jump test, there was no significant difference in results between UAE and non-UAE football players. Average time to turn for dominant and non-dominant sides did not show any significant difference, for either group.

Conclusion

There is no difference in 6-s tapping, Chase 15-s tests or limb asymmetry amongst UAE and Non-UAE footballers. However, the non-UAE footballers showed significantly better performance in Countermovement Jump Test. The data provide baseline values for forthcoming sports medicine research, which can be taken into account when creating injury prevention or return-to-sport protocols, particularly with regard to change of direction parameters and countermovement jump.

Insurance cost and injury characteristics of anterior cruciate ligament injuries in sub-elite football: A population analysis involving 3 years of Australian insurance data

OBJECTIVES

To investigate the injury characteristics and insurance cost of anterior cruciate ligament injuries in sub-elite football players in New South Wales, Australia.

DESIGN

Descriptive epidemiological study.

METHODS

Three years of insurance records (2018-2020) was used to describe anterior cruciate ligament injury costs and characteristics. Concomitant injuries and the mechanism of injury were determined by analysing the injury descriptions. Claim characteristics and costs are presented by age group (junior = 7-17 years, senior = 18-34 years, and veteran = 35 + years) and sex. Categorical data (including age-groups and sex) are presented as counts and percentages and analysed using a Chi squared or Fisher's exact test. Cost data are reported as means ± standard deviation with 95 % confidence intervals.

RESULTS

Over the course of three football seasons (2018-2020), 786 anterior cruciate ligament injuries were reported to the injury insurance company. The total insurance cost was AU$3,614,742 with direct injury insurance costs accounting for 36.3 % of the total costs. The mean indirect insurance costs were six-fold higher than direct insurance costs (AU$11,458 vs AU$1914). Isolated injuries had an average cost of $4466 whilst concomitant injuries had an average cost of $4951. Surgical costs are excluded from direct cost calculations. The peak injury count occurred in the first month of all three football seasons, immediately after the pre-season.

CONCLUSIONS

Anterior cruciate ligament injuries represent a substantial economic burden to the insurer and individual. The cost data provided can be used for future economic and modelling studies.

High revision arthroscopy rate after ACL reconstruction in men's professional team sports

PURPOSE

The study analysed unique data on anterior cruciate ligament (ACL) injuries among German professional male team sports over five consecutive seasons with the aim of improving medical outcomes in the future. Sport-specific differences in injury occurrence, concomitant injuries, timing of ACL reconstruction, graft type selection and short-term complications were examined.

METHODS

This retrospective study analysed trauma insurance data on all complete ACL tears from players with at least one competitive match appearance in the two highest divisions of German male basketball, ice hockey, football and handball. Each complete ACL tear registered by clubs or physicians between the 2014/15 and 2018/19 seasons with the German statutory accidental insurance for professional athletes (VBG) as part of occupational accident reporting was included.

RESULTS

In total, 189 out of 7517 players (2.5%) sustained an ACL injury, mainly in handball (n = 82; 43.4%) and football (n = 72; 38.1%) followed by ice hockey (n = 20; 10.6%) and basketball (n = 15; 7.9%).Seventeen players (9.0%) also sustained a second ACL injury. Thus, 206 ACL injuries were included in the analysis. The overall match incidence of ACL injuries was 0.5 per 1000 h and was highest in handballs (1.1 injuries per 1000 h). A total of 70.4% of ACL injuries involved concomitant injury to other knee structures, and 29.6% were isolated ACL injuries. The highest rate of isolated ACL injuries was seen in ice hockey (42.9%). All ACL injuries, except for one career-ending injury, required surgery. In the four analysed team sports, hamstring tendons (71.4%) were the most commonly used grafts for ACL reconstruction; football had the highest percentage of alternative grafts (48.7%). During rehabilitation, 22.9% of all surgically treated ACL injuries (n = 205) required at least two surgical interventions, and 15.6% required revision arthroscopy. The main cause of revision arthroscopy (n = 32; 50.0%) was range-of-motion deficit due to arthrofibrosis or cyclops formation.

CONCLUSION

The present study shows an overall high rate of revision arthroscopy after ACLR (15.6%), which should encourage surgeons and therapists to evaluate their treatment and rehabilitation strategies in this specific subpopulation. Hamstring tendon grafts are most commonly used for ACL reconstruction but have the highest revision and infection rates. Handball shows the highest ACL injury risk of the four evaluated professional team sports. Concomitant injuries occur in the majority of cases, with the highest share of isolated ACL injuries occurring in ice hockey.

LEVEL OF EVIDENCE

Level III.

Reduced performance after return to competition in ACL injuries: an analysis on return to competition in the 'ACL registry in German Football'

PURPOSE

ACL injuries are one of the most severe injuries in football, but medical consequences and performance outcomes after return to competition are only rarely investigated. Aim of this study was to analyse the time of return to competition (RTC) in German professional, semi-professional and amateur football. Also, this investigation highlights the rate of career ending and performance outcome after RTC in different playing levels by the measurement of playing level, performed matches and played minutes.

METHODS

Database of this investigation is the 'ACL registry in German Football' with prospectively collected injury data. Between 2014 and 2018, four seasons in professional (1st-3rd league), semi-professional (4th-6th league) and amateur leagues (7th league) were analysed regarding the return to competition period and performance parameters. Data were collected for three subsequent seasons after injury and compared with the pre-injury and injury season. Data collection was performed using standardized methods.

RESULTS

A total of 607 ACL injuries were registered during the 4-year period with a mean RTC time of 337.1 day (SD: 183). After primary ACL ruptures, the fastest RTC was found in professional football (247.3 days), while in semi-professional (333.5 d; p < 0.0001) and amateur football (376.2 d; p < 0.0001) a prolonged absence was detected. Re-ruptures occurred in 17.8% (n = 108) and showed similar trend with fastest RTC in professionals (289.9 days; p = 0.002). Within the first three seasons after injury, 92 players (36.7%) in semi-professional and 24 (20%) in professionals had to end their career. Keeping the level of play was only possible for 48 (47.5%) of professionals, while only 47 (29.6%) of semi-professionals and 43 (28.1%) of amateurs were able to. Only in professional football, no significant difference could be seen in the played minutes and games after 2 years compared to the pre-injury season.

CONCLUSION

Lower playing levels and re-ruptures are the main factors for a prolonged return to competition after ACL rupture in German football. Significant reduction in playing level and a high rate of career endings were found for all levels of play. However, only professional players were able to regain their playing minutes and games 2 years after injury, while lower classed athletes did not reach the same amount within 3 years.

LEVEL OF EVIDENCE

Level III.

Smaller intercondylar notch size and smaller ACL volume increase posterior cruciate ligament rupture risk

PURPOSE

Little is known about risk factors for sustaining a posterior cruciate ligament (PCL) rupture. Identifying risk factors is the first step in preventing a PCL rupture from occurring. The morphology of the knee in patients who ruptured their PCL may differ from that of control patients. The hypothesis was that the intercondylar notch dimensions, 3-D volumes of the intercondylar notch and, the 3-D volumes of both the ACL and the PCL were correlated to the presence of a PCL rupture.

METHODS

The magnetic resonance imaging (MRI) scans of 30 patients with a proven PCL rupture were compared to 30 matched control patients with proven intact ACL and PCL. Control patients were selected from patients with knee trauma during sports but without cruciate ligament injury. Patients have been matched for age, height, weight, BMI, and sex. The volumes of the intercondylar notch and both the ACL and PCL were measured on 3D reconstructions. Second, the bicondylar width, the notch width, and the notch width index were measured of all subjects. The relationship between our measurements and the presence of a PCL rupture was analysed.

RESULTS

The results show a significant difference in the volumes of the intercondylar notch and the ACL between patients with a ruptured PCL and control patients. Patients with a PCL rupture have smaller intercondylar notch volumes and smaller ACL volumes. There were no significant differences in the bicondylar width, notch width, and notch width index. In the control patients, a significant correlation between the volume of the PCL and the volume of the ACL was found (0.673, p < 0.001).

CONCLUSION

Patients with a PCL rupture have smaller intercondylar volumes and smaller ACL volumes when compared to control patients. Second, patients with smaller ACL volumes have smaller PCL volumes. This study shows, for the first time, that there are significant size and volume differences in the shape of the knee between patients with a PCL rupture and control patients.

LEVEL OF EVIDENCE

IV.

Injury prevention programs including balance exercises with compliance and follow-up reduce the incidence of knee injuries in athletes: A systematic review and meta-analysis

BACKGROUND: The knee is one of the most common injuries in sports. However, the incidence of knee injuries can be decreased by enhancing balance and neuromuscular control. OBJECTIVE: The aim of this systematic review and meta-analysis was to investigate how injury prevention programs (IPPs) that include balance training influence knee injury rates in athletes. METHODS: Data were obtained from different databases (1985–2021). Only randomised controlled trials that used IPPs that include balance training, were considered. Two investigators extracted data from the qualifying documents. The critical outcome data elements derived from the included studies were the number of ACL/knee injuries, ACL/knee injury rates, exposure hours, compliance rate, and follow-up duration. RESULTS: Compared to the control groups, those who participated in the IPP had a 54% lower risk of knee injuries per 1000 hours of exposure (IRR 0.457 (95% CI 0.346–0.603), P= 0.001) and a 60% lower risk of ACL injuries per 1000 hours of exposure (IRR 0.401 (95% CI 0.215–0.750), P= 0.004). CONCLUSIONS: IPPs that include balance training may reduce the risk of knee injuries.

Video analysis of 100 matches in male semi-professional football reveals a heading rate of 5.7 headings per field player and match

INTRODUCTION

Heading is an integral part of football and frequent media reports and previous studies about potential danger of heading and head trauma in football fuelled discussions. Epidemiological data and video analyses regarding headings situation and associated head injuries are still missing in male adult professional football.

METHODS

In a prospective cohort study in the male fourth German football league, 100 official matches of the 2015-2016 season were assessed by video analysis and a standardized protocol. Heading situations and concomitant circumstances as well as incidents with a propensity of injury (critical incidents) were analyzed. Critical incidents (CI) and seasonal reported head injuries were cross-referenced.

RESULTS

Overall, 11,514 headings were analysed in detail. Video analysis yielded a mean of 5.7 headings per player and match (SD: 1.2; range 0-15). Heading was predominantly performed with the frontal part of the head (76.8%), and nearly two thirds of all headings occurred during defending (65.8%). 71.0% of all headings occured during tacklings, of which 71.9% involved body contact with the opponent player. Video analysis yielded 31 CI on the head due to heading (incidence: 1.02 per 1000 h match exposure and player). 29 CI occurred during heading duels (odds ratio: 5.91), 30 CI with body contact (odds ratio: 28.8) and 6 CI with elbow contact (odds ratio: 6.13).

CONCLUSION

Heading frequency in male semi-professional football could be determined with a rate of 5.7 headings per match and field player. Cross referencing CI and seasonal reported head injuries revealed a very low number of reported head injuries.

No increased injury incidence in the German Bundesliga after the SARS-CoV-2 virus lockdown

INTRODUCTION

The coronavirus lockdown in 2020 resulted in a worldwide suspension of professional sports. The first major professional football league to restart after the lockdown was the German Bundesliga. This study investigates whether the injury incidence increased after the restart of the season with only 9 days of regular preparation time and without any friendly matches in comparison to three control periods.

MATERIALS AND METHODS

In a prospective cohort study, injury analysis (at least 1 day of absence from official football matches or training sessions) of the German Bundesliga registry was standardised according to Hägglund et al. (Br J Sports Med 39:340-346, 2005) and Fuller et al. (Clin J Sports Med 16:97-106, 2006) for data collection and to previous publications for the validated use of media sources for injury registration. The study period after the lockdown in May and June of the 2019-2020 season was compared to three control periods: the period directly before the lockdown, the beginning of the 2019-2020 season and the 2018-2019 season final.

RESULTS

The nine match days after the restart of the 2019-2020 season showed an overall injury incidence of 4.9 per 1000 h football. This rate was significantly lower than that of the previous season final (9 last match days, overall injury incidence: 6.9 per 1000 h football; p < 0.001) and not increased compared to the rates after the summer break (9 match days; incidence: 5.5/1000 h, p > 0.05) or the winter break (8 match days; incidence: 5.6/1000 h, p > 0.05).

CONCLUSION

The period after the unexpected break in the 2019-2020 season due to the coronavirus lockdown and the rapid return to competition showed no increase in the injury rate compared to the pre-lockdown period and a lower injury rate than in the previous season final. The unintentional mid-season rest with its potential for physical recovery and individual fitness training seems to have had a positive effect on injury occurrence.

Non-contact Anterior Cruciate Ligament Injury Epidemiology in Team-Ball Sports: A Systematic Review with Meta-analysis by Sex, Age, Sport, Participation Level, and Exposure Type

Background

Not all anterior cruciate ligament (ACL) injuries are preventable. While some ACL injuries are unavoidable such as those resulting from a tackle, others that occur in non-contact situations like twisting and turning in the absence of external contact might be more preventable. Because ACL injuries commonly occur in team ball-sports that involve jumping, landing and cutting manoeuvres, accurate information about the epidemiology of non-contact ACL injuries in these sports is needed to quantify their extent and burden to guide resource allocation for risk-reduction efforts.

Objective

To synthesize the evidence on the incidence and proportion of non-contact to total ACL injuries by sex, age, sport, participation level and exposure type in team ball-sports.

Methods

Six databases (MEDLINE, EMBASE, Web of Science, CINAHL, Scopus and SPORTDiscus) were searched from inception to July 2021. Cohort studies of team ball-sports reporting number of knee injuries as a function of exposure and injury mechanism were included.

Results

Forty-five studies covering 13 team ball-sports were included. The overall proportion of non-contact to total ACL injuries was 55% (95% CI 48–62, I² = 82%; females: 63%, 95% CI 53–71, I² = 84%; males: 50%, 95% CI 42–58, I² = 86%). The overall incidence of non-contact ACL injuries was 0.07 per 1000 player-hours (95% CI 0.05–0.10, I² = 77%), and 0.05 per 1000 player-exposures (95% CI 0.03–0.07, I² = 97%). Injury incidence was higher in female athletes (0.14 per 1000 player-hours, 95% CI 0.10–0.19, I² = 40%) than male athletes (0.05 per 1000 player-hours, 95% CI 0.03–0.07, I² = 48%), and this difference was significant. Injury incidence during competition was higher (0.48 per 1000 player-hours, 95% CI 0.32–0.72, I² = 77%; 0.32 per 1000 player-exposures, 95% CI 0.15–0.70, I² = 96%) than during training (0.04 per 1000 player-hours, 95% CI 0.02–0.07, I² = 63%; 0.02 per 1000 player-exposures, 95% CI 0.01–0.05, I² = 86%) and these differences were significant. Heterogeneity across studies was generally high.

Conclusion

This study quantifies several key epidemiological findings for ACL injuries in team ball-sports. Non-contact ACL injuries represented over half of all ACL injuries sustained. The proportion of non-contact to total ACL injuries and injury incidence were higher in female than in male athletes. Injuries mostly occurred in competition settings.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40279-022-01697-w.

The relationship between eccentric hamstring strength and dynamic stability in elite academy footballers

OBJECTIVES

Previous research describes dynamic stability and functional strength as key aetiological risk factors associated with lower limb non-contact musculoskeletal injury. Due to the multifactorial nature of injury risk, relationships between the two factors will inform injury management and training design.

METHODS

A total of 59 elite academy footballers from two English premier league category 1-status academies completed the study. All players completed measures of eccentric hamstring strength and dynamic stability. Relationships between directional stability (Anteroposterior (Ant), Posteromedial (PM) and Posterolateral (PL)) and eccentric strength metrics (PkT, AvT, PkF, AvF and Ɵ) bilaterally were identified for analysis.

RESULTS

Significant correlations were identified bilaterally for functional hamstring strength metrics and PM and PL stability (P ≤. 0.05). No significant relationships were identified between anterior stability and eccentric hamstring strength parameters (P > 0.05).

CONCLUSIONS

Eccentric hamstring strength has a positive influence on directional stability through two planes, PM and PL. The lack of influence of eccentric hamstring strength on Ant directional stability could be attributed to increased ACL risk. Careful consideration of the significance of the relationships between eccentric hamstring strength and directional stability must be given when quantifying injury risk in elite academy footballers.

Higher risk of ACL rupture in amateur football compared to professional football: 5-year results of the 'Anterior cruciate ligament-registry in German football'

PURPOSE

Anterior cruciate ligament (ACL) injuries are a common severe type of football injury at all levels of play. A football-specific ACL registry providing both prospective ACL injury data according to the skill level and risk factors for ACL injury is lacking in the literature.

METHODS

This study is based on the prospective 'ACL registry in German Football' implemented in the 2014-15 season. Professional (1st-3rd league), semi-professional (4th-6th league) and amateur leagues (7th league) were analysed regarding the incidence and risk factors for ACL injuries. Injuries were registered according to the direct reports of the injured players to the study office and double-checked via media analysis. After injury registration, the players received a standardised questionnaire. Data were analysed from the 2014-15 to the 2018-19 football season.

RESULTS

Overall, 958 ACL injuries were registered during the 5-year study period. The incidence of ACL injuries was highest in amateur football (0.074/1000 h football exposure) compared to professional (0.058/1000 h; p < 0.0001) and semi-professional football (0.043/1000 h; p < 0.0001). At all skill levels, match incidence (professional: 0.343; semi-professional: 0.249; amateur: 0.319) was significantly higher than training incidence (professional: 0.015; semi-professional: 0.004; amateur: 0.005). Major risk factors were previous ACL injury (mean: 23.3%), other knee injuries (mean: 19.3%) and move to a higher league (mean: 24.2%).

CONCLUSION

This sports-specific ACL registry provides detailed information on the incidence and risk factors for ACL injuries in football over five years. Risk factors are skill level, match exposure, move to a higher league and previous knee injury. These factors offer potential starting points for screening at-risk players and applying targeted prevention.

LEVEL OF EVIDENCE

II.

Epidemiological analysis of injury occurrence and current prevention strategies on international amateur football level during the UEFA Regions Cup 2019

INTRODUCTION

Football is the most popular sport worldwide and results in a high frequency of injuries. So far, mainly injuries in professional football have been investigated, and the literature lacks data regarding detailed injury epidemiology and current prevention data in amateur football tournaments.

MATERIALS AND METHODS

A prospective cohort study investigated an international amateur football tournament, the UEFA Regions' Cup, which took place in 2019 in Germany. Injury epidemiology, current prevention strategies of the teams and the implementation of the UEFA concussion protocol were investigated in detail by means of standardized injury definitions and data samples for football (Fuller et al., Scand J Med Sci Sports 16:83-92, https://doi.org/10.1111/j.1600-0838.2006.00528.x , 2006).

RESULTS

138 player of 8 teams participated in this study, while 39 players were excluded. Overall injury incidence was 12.5 per 1000 h total football exposure, 43.5 per 1000 h for match exposure. No injuries were registered during training. Injury prevalence was 14.1% per player and 1.1 injuries per match were registered. The lower extremity was predominantly affected by injuries (71.4%) and the majority of injuries (78.6%) were non-severe injury types like contusions (50%) and sprains (18.2%). Two head injuries, one contusion and one skin lesion, were handled by the guidelines of the UEFA concussion protocol. 44.4% of the players indicated at least one previous injury before tournament, 45.3% of them during the last two football seasons before start of the tournament. Injury prevention performance was included in all participating teams during the tournament by warm up or training strategies (100%). During the warm-up program just 5 exercises of the FIFA 11 + program was detected by this investigation in participating teams to be done by more half of the teams. Running exercises were the most frequently performed exercises, while trunk muscle exercises were less represented (14.3%).

CONCLUSION

This study presents for the first time epidemiological injury and prevention data of the UEFA Regions Cup. Injury incidence was higher compared to injury reports of regular seasons, but lower compared to other amateur football tournaments. Currently used prevention programs revealed trunk muscle exercises as often neglected.

Timing return-to-competition: a prospective registration of 45 different types of severe injuries in Germany's highest football league

INTRODUCTION

Many professional football players sustain at least one severe injury over the course of their career. Because detailed epidemiological data on different severe injuries in professional football have been missing so far, this study describes the frequency and return-to-competition (RTC) periods of different types of severe football injuries.

MATERIAL AND METHODS

This epidemiological investigation is a prospective standardised injury analysis based on national media longitudinal registration. Injuries were classified according to the consensus statement by Fuller et al. (2006). The analysis includes injuries sustained by players of the first German football league during the seasons 2014-2015 to 2017-2018.

LEVEL OF EVIDENCE

II.

RESULTS

Overall, 660 severe injuries were registered during the four seasons (mean 165 per season; 9.2 per season per team; incidence in 1000 h: 0.77). The body region most frequently affected by severe injury was the knee (30.0%; 49.5 injuries per season/SD 13.2) followed by the thigh (26.4%; 43.5 injuries/SD 4.2) and the ankle (16.7%; 27.5 injuries/SD 5.0). The distribution of injuries over the course of a season showed a trend for ACL ruptures to mainly occur at the beginning of a season (45.8%), overuse syndromes such as achillodynia (40.9%) and irritation of the knee (44.4%) during the winter months and severe muscle and ankle injuries at the end of a season. ACL ruptures showed the longest RTC durations (median 222 days).

CONCLUSION

This study presents detailed epidemiological data on severe injuries in professional football. The body region most frequently affected by severe injuries was the knee. Several types of severe injuries showed a seasonal injury pattern. The appropriate timing of RTC after an injury is one of the most important and complex decisions to be made. This study provides information on the typical time loss due to specific severe football injuries, which may serve as a guideline.

Increased occurrence of ACL injuries for football players in teams changing coach and for players going to a higher division

PURPOSE

To identify football-specific factors associated with ACL injuries that can be targeted for sport-specific injury prevention.

METHODS

A study-specific questionnaire was developed to study the characteristics of ACL injuries in football including intrinsic, extrinsic, and injury specific factors. The questionnaire was available at the Swedish national knee ligament registry's website for the football players to voluntarily fill out. Data are presented on group level for all football players in total and for females and males separate to examine gender-specific differences. The results are based on answers collected over a 3-year period from 2875 football players, 1762 (61%) males and 1113 (39%) females.

RESULTS

ACL were more frequently sustained during games 66% than during practices 25%. The injury mechanism was non-contact in 59% and contact in 41%. For the contact injuries during games, no action was taken by the referee in 63% of the situation and a red card was shown in 0.5%. The risk of ACL injury was highest early in the football game with 47% sustained during the first 30 min and 24% in the first 15 min. Players changing to a higher level of play 15% had a higher rate of ACL injuries than players changing to a lower level 8%. This difference was especially seen in female football players with 20% of ACL injuries being sustained by players going to a higher division compared to 7% for those going to a lower division. 15% of the male and 21% of the female ACL injuries occurred in teams with a coach change during the season. Knee control exercises to warm up was used by 31% of the female players and 16% of the males. 40% of the players reported that they did not plan on returning to football.

CONCLUSION

Neuromuscular training programs have proven to reduce ACL injuries, but greater adherence to these remains a challenge as only 1 in 5 of the ACL-injured football players report using them. Teams changing coach and players going to a higher division appear to have an increased risk of ACL injury warranting attention and further investigations.

LEVEL OF EVIDENCE

IV.

An increasing trend of posterior cruciate ligament reconstruction in South Korea: epidemiologic analysis using Korean National Health Insurance System Database

Background

The posterior cruciate ligament is crucial for posterior stability of the knee joint, and, as well as anterior cruciate ligament reconstruction, posterior cruciate ligament reconstruction (PCLR) has attracted interest in orthopedic literature. A few studies have investigated epidemiologic data of PCLR in Western countries. However, there has been no report on the epidemiological pattern of PCLR in the Asian population, including South Korea. Therefore, this study investigated the incidence and trends of PCLR in South Korea using the Korean National Health Insurance (NHI) System Database.

Methods

The data was collected by the Korean Health Insurance Review and Assessment Service (HIRA) from 2008 to 2016 in South Korea. Patients with a record of cruciate ligament reconstruction and PCLR were allocated from the database. An analysis of the total number and incidence per 100,000 people/year of PCLR procedures and other epidemiologic parameters was conducted according to sex and age.

Results

The incidence of PCLR procedures rose from 2.3 to 2.6 per 100,000 people (from 1101 to 1299 total cases; 13% increase) between 2008 and 2016: from 3.8 to 4.0 (from 901 to 1000) in males, and from 0.8 to 1.2 (from 200 to 299) in females. PCLR was performed more frequently in males than in females, however, the rate of increase was higher in females than males. The incidence of PCLR over 9  years was highest in patients in their 20s, followed by patients in their 40s and 30s.

Conclusion

The incidence of PCLR procedures increased by 13% over 9 years in South Korea. PCLR was performed approximately three times more in men than in women. The incidence of PCLR was highest in patients in their 20s, followed by those in their 40s. The current study will enhance our understanding of the epidemiology of PCLR.

Study design

Descriptive Epidemiology Study.

High injury rates and weak injury prevention strategies in football referees at all levels of play

Football referees need other physiological requirements on field than football players and are affected by different types of injury. The absence of referees may result in canceled matches, so special focus should be placed on injury prevention through specific training programs for referees. This study retrospectively analyzed injury occurrence and prevention strategies for German football referees at the different levels of play over one season. Data were collected by means of seasonal injury reports based on the consensus statement of injury definition and data collection. Of the 923 participating referees, 91 (9.9%) played at the professional level, 151 (16.3%) at the semi-professional, and 681 (73.8%) at the amateur level. 86.2% (n = 796) were men and 13.8% (n = 127) women. Referees at the amateur level showed the highest injury incidence (3.14/1000 h football) compared to referees at the semi-professional (1.92/1000 h; p < 0.001) and professional level (1.01/1000 h; p < 0.001). Most referees at the amateur (n = 372; 56.4%) and semi-professional level (n = 46; 31.3%) conducted warm-up programs of <10 min, whereas the mean warm-up duration of professional referees was >11 min (n = 75; 82.4%). Although running and stretching exercises were common among referees during warm-up, preventive exercises focusing on coordination and trunk muscles were less frequent, especially among amateur referees (jumping: 15.9%; strengthening: 9.7%; balance exercises: 7.9%). Injury incidence was highest at lower amateur levels, which thus has specific need for injury prevention. Appropriate training exercises to prevent injuries of referees were weak at all levels of play, especially the lack of strength, plyometric, and balance exercises in training and warm-up programs.

Return to competition after anterior cruciate ligament injuries in world class judoka

OBJECTIVES

The purpose of this study was to quantify how the return to competition after an anterior cruciate ligament rupture in Judo is perceived by athletes as compared to doctors and physiotherapists. Is there a difference between the perspectives of doctors and physiotherapists and athletes regarding surgery, time loss due to injury, or the level of performance after the injury? Which functional tests are used to define when or if athletes are ready for the return to competition?

METHODS

A survey-based retrospective study design with two surveys regarding the treatment methods of an anterior cruciate ligament rupture was established: one version for athletes and one for doctors and physiotherapists. Surveys were equivalent for both populations despite the athletes' individual data. Variance analysis was applied to assess if statistically meaningful differences exist between the two groups.

RESULTS

From 232 judoka interviewed during the Junior World Judo Championships 2017, 23 suffered an anterior cruciate ligament rupture in the last 2 years. As high as 52% underwent surgery. According to doctors and physiotherapists, 82% of athletes underwent reconstructive surgeries. Athletes returned to competition after 5.5 months, whereas doctors and physiotherapists assumed a time loss of 8.4 months. Only 44% of the doctors and physiotherapists used functional tests like hop tests for defining return to competition and 22% used mental tests. When asking athletes, the use of hop tests (8%) and mental tests (0%) was even lower.

CONCLUSION

The study demonstrated for the first time significant discrepancies between the medical treatment regarding the recommendations of doctors and physiotherapists compared to athletes behavior. To support a conclusive statement, we should encourage the doctors and physiotherapists to use functional test batteries for the decision-making process regarding return to competition.

Head injuries in professional football (soccer): Results of video analysis verified by an accident insurance registry

BACKGROUND

Video analysis is one of the most commonly applied methods for analysing football injuries.

PURPOSE

The objective of this study was to assess the accuracy of video analysis for recording head injuries in professional football from official matches in the four highest men's professional football leagues in Germany.

METHODS

In this cohort study, head injuries detected by means of video analysis of all official matches over one season (2017-18) were compared to head injuries registered with the German statutory accident insurance.

RESULTS

Our video analysis yielded 359 head injuries of 287 players. The comparison of head injuries found in our video analysis to those registered with the accident insurance only yielded a match in 23.1% (n = 83), which presents a rather low verification rate. The verification rates varied between the leagues (7.0-30.8%). All injuries documented in the accident insurance registry were found in the video analysis (100%). The types of head injury most often verified by the accident insurance registry (n = 83) were contusion (43.4%), bone fractures (19.3%) and skin lacerations (18.1%). Only 66 of the 359 head injuries (18.4%) resulted in absence from at least one training session and involved a mean time loss of 18.5 days (1-87 days).

CONCLUSION

The mismatch between the number of head injuries found in the video analysis and head injuries registered with the accident insurance is an important methodological issue in scientific research. The low verification rate seems to be due to the unclear correlation between injury severity and clinical consequences of head injuries detected by means of video analysis and the failure of football clubs to register minor head injuries with the accident insurance.

Decision-making to stop or continue playing after football injuries - a systematic video analysis of 711 injury situations in amateur football

Scientific injury registration via video analysis is lacking in amateur football. The purpose of this study was to analyse match injury situations with a focus on the decisions made by players and referees after sustaining a football trauma. In a retrospective cohort study, traumatic injuries sustained in any of the 305 matches of the highest amateur level (4th league) in Germany in the 2015-16 season were assessed by means of video analysis and a standardised video protocol. In total, 711 traumatic incidents at 919 different body regions had been recorded. The three most frequently injured body regions were the ankles (34.1%), the head (17.5%) and the knees (17.0%). 90% (n = 156) of head injuries were direct contact injuries, this percentage was significantly higher than that of contact injuries on ankle (68.4%; p < 0.001) or knee (52.6%; p = 0.001). Referees decided on foul play significantly more often in case of knee injuries (57.1%; p = 0.002) or ankle injuries (64.5%; p < 0.001) than in head injuries (39.8%). Only 26.1% of players with a head injury opted for substitution, which was lower than after ankle (27.8%; p = 0.78) and knee injuries (34.0%; p = 0.13). In conclusion, amateur football is associated with a considerable number of injury situations that are followed by match interruptions and the substitution of players. Players and referees decided to continue playing more often after a head injury than after an injury to other body regions. An advanced education programme on the risks and management of head injuries in football is required to prevent long-term health consequences.

Injury Profile and Sex-Specific Differences in Bubble-Soccer - A First Scientific Survey of a Dangerous New Sports Trend

Purpose

Small-field soccer is a popular type of amateur sports worldwide. One type of small-field soccer growing in popularity is bubble-soccer, but injury risks and injury patterns are still unclear. This study investigates the factors influencing injuries in bubble-soccer for the first time.

Materials and Methods

This prospective cohort study of an outdoor tournament investigated the injury incidence and injury patterns as well as the factors influencing injuries in bubble-soccer matches. Data were collected according to the statement on data collection and injury definition. Preparation and physical outcome were assessed for both sexes.

Results

Of 145 players (104 men, 41 women), 58 players sustained 94 injuries during the tournament and 64% of injuries affected the lower extremities. The most common traumatic injuries were skin lesions (37.5%), acute pain (15.6%) and contusion (7.8%). More female players (3818.2/1000 h bubble-soccer) than male players (1474.4) were affected by injury, mostly to the knees or the head. Also, women significantly more often reported neck pain than men (p<0.042); 29.0% of players felt uncomfortable wearing the bubble, and 21.4% reported neurological symptoms such as headache or dizziness after the match.

Conclusion

Bubble-soccer shows a relatively high injury incidence. Women had a higher injury incidence and were more often affected by traumatic injuries to the head and neck including feeling of discomfort and headache or neck pain after the match. Adequate preparation seems to be essential for injury prevention, and players should recognise the high injury risk of bubble-soccer.

Nine typical injury patterns in German professional male football (soccer): a systematic visual video analysis of 345 match injuries

AIM

We aimed to systematically analyse the videos of acute injuries in professional men's football and describe typical injury patterns.

METHODS

Injuries were registered with the German statutory accident insurance for professional athletes as part of occupational accident reporting. Following each season (2014-2017), video footage of the two highest divisions in German male football was searched for moderate and severe acute match injuries. Two raters then independently assessed the injuries for: game situation, player and opponent behaviour, referee decision, and injury mechanisms.

RESULTS

The total data set included 7493 acute injuries. Of these, 857 (11%) were moderate or severe match injuries. The video search yielded 345 (40%) clearly identifiable injuries and of those 170 (49%) were contact injuries. We describe nine typical injury patterns: one each for head and shoulder injuries, two for thigh and ankle, and three for knee injuries. The nine patterns are called: (1) Head-to-head injury. (2) Collision-and-fall shoulder injury. (3) Sprinter's thigh injury. (4) Perturbation-and-strain thigh injury. (5) Tackle knee injury. (6) Tackle-and-twist knee injury. (7) Non-contact knee injury. (8) Attacked ankle injury. (9) Collision-and-twist ankle injury. Thigh injuries occurred primarily in non-contact situations (44/81), mostly while the player was sprinting (23/44). Knee injuries were often caused by direct external impact (49/84)-mainly suffered by the tackler during a tackle (17/49).

CONCLUSION

The nine common injury patterns in football differed substantially in their mechanisms and causes.

Injury Analysis in Professional Soccer by Means of Media Reports - Only Severe Injury Types Show High Validity

Purpose

Injury data of professional soccer players obtained from media reports are frequently used in scientific research, but the accuracy of such data is still unclear.

Patients and Methods

Injuries of professional soccer players of the German first and second league were documented by continuously screening media reports over one season (2015-2016). After the season, the validity of media-reported injuries was anonymously analyzed by the team physicians of 8 different soccer clubs.

Results

A total of 255 injuries of 240 players of 8 professional soccer teams had been published online, of which 146 were confirmed by the team doctors as correct, yielding a rate of 57.3% of confirmed media-reported injuries. In addition, 92 injuries without media registration were detected and added to the online statistics, resulting in 347 injuries and an overall weak validity of media-based data of 42.1%. Statistical analysis showed that the validity of media-reported injury data depended on both the individual soccer club and the body site affected by injury: publications on knee injuries (78.2%) had a higher validity than those on foot injuries (46.2%), and publications on severe injuries had a higher validity (joint dislocation: 100%; ligament rupture: 82.9%; fracture: 73.3%) than those on minor injuries. Publications on specific severe soccer injuries, such as anterior cruciate ligament (ACL) injuries, had a validity of 100%.

Conclusion

Media-based injury data were only valid for a few severe injury types such as ACL injuries. In daily soccer routine and scientific research, media-based data should thus only be used in combination with specific criteria or verification processes.

Epidemiological Data on LCL and PCL Injuries Over 17 Seasons in Men's Professional Soccer: The UEFA Elite Club Injury Study

Background

There is limited epidemiological information on injury rates and injury mechanisms for lateral collateral ligament (LCL) and posterior cruciate ligament (PCL) injuries in male professional soccer. In addition, time trends and lay-off times for these injuries have not yet been determined.

Aim

To determine injury rates and circumstances of LCL and PCL injuries over 17 seasons in men’s professional soccer.

Methods

A prospective cohort study, in which 68 professional European soccer teams were followed over 17 consecutive seasons (2001/2002 to 2017/2018). The teams’ medical staff recorded player exposure and time-loss injuries. Lay-off time was reported as the median and the first and third quartile. Injury rate was defined as the number of injuries per 1000 player-hours.

Results

One hundred and twenty-eight LCL and 28 PCL injuries occurred during 2,554,686 h of exposure (rate 0.05 and 0.01/1000 h, respectively). The median lay-off time for LCL injuries was 15 (Q₁=7, Q₃=32) days, while it was 31 days for PCL injuries (Q₁=15, Q₃=74). The match injury rate for LCL injuries was 11 times higher than the training injury rate (0.21 vs 0.02/1000 h, rate ratio [RR] 10.5, 95% CI 7.3 to 15.1 p<0.001) and the match injury rate for PCL injuries was 20 times higher than the training injury rate (0.056 vs 0.003/1000 h, RR 20.1, 95% CI 8.2 to 49.6, p<0.001). LCL injuries saw a significant annual decrease of approximately 3.5% (p=0.006). In total, 58% (63/108) of all LCL injuries and 54% (14/26) of all PCL injuries were related to contact mechanism.

Conclusion

This study with prospectively registered data on LCL and PCL injuries in men’s professional soccer shows that the median lay-off from soccer for LCL and PCL injuries is approximately 2 and 4 weeks respectively. These rare knee ligament injuries typically occur during matches and are associated with a contact injury mechanism.

Injury burden differs considerably between single teams from German professional male football (soccer): surveillance of three consecutive seasons

PURPOSE

The purpose of this study was to analyse unique injury data of the national statutory accident insurance for the two highest divisions in German male football (Bundesliga and 2. Bundesliga) over three consecutive seasons regarding inter-season, inter-division and inter-team differences.

METHODS

This was a prospective observational open cohort study over the seasons 2014/2015, 2015/2016 and 2016/2017. Every acute injury that was registered by clubs or physicians with the German statutory accident insurance for professional athletes (VBG) as part of occupational accident reporting and that led to time loss and/or to medical attention, was included.

RESULTS

The complete sample consisted of 1449 players. The study covered 2663.5 player seasons with an observed match exposure of 69,058 h and a projected training exposure of 529,136 h. In total, 7493 injuries were included. The overall incidence rate was 12.5 (± 0.28) injuries per 1000 exposure hours, which translated into match and training rates of 47.0 (± 1.62) and 8.02 (± 0.24) injuries per 1000 h, respectively.

CONCLUSION

Findings of 2.7 injuries per player and season underline the need of effective preventive approaches. Higher injury incidences in seasons after international tournaments suggest an increasing risk of injury with increasing number of matches. However, large differences between the single teams from the same division indicate that a reduction in the injury burden is generally possible. Continuing the presented injury surveillance might be helpful to identify injury trends in the future and to evaluate the effectiveness of preventive approaches under real-life conditions.

LEVEL OF EVIDENCE

Level  II.

Influence of poor preparation and sleep deficit on injury incidence in amateur small field football of both gender

INTRODUCTION

Amateur small-field football tournaments are rather common worldwide. Adequate preparation is essential for injury prevention. The consequences of insufficient injury preparation at this level are still unclear. This study investigates the factors influencing injuries in this football population.

MATERIALS AND METHODS

In 2017, medical students participating in a national amateur football tournament were analysed in a prospective cohort study. Injury incidence, injury pattern and factors influencing injuries were investigated according to the statement on data collection and injury definition of Fuller et al. (Br J Sports Med 40:193-201, 2006). Preparation for the tournament was assessed for both sexes by means of hours of sleep, alcohol consumption, training level and warm-up performance.

LEVEL OF EVIDENCE

II.

RESULTS

Of 694 amateur football players (423 men and 271 women) with a mean age of 23 years (SD 2.5), 321 (21.1%) injuries happened during the tournament. 60% of injuries affected the lower extremity. The most common types of traumatic injury were skin abrasions (40.0%) and muscle strains (23.3%). The injury incidence of male players during match exposure was 469 per 1000 h football and significantly higher than in female players 313 (p = 0.025). One potential reason for the higher injury rate of male players as measure for inadequate preparation was significantly higher alcohol consumption the evening before the tournament (p < 0.001) and the after-effects on match day (p < 0.001). Additionally, male players reported less and inadequate sleep the night before the tournament (p < 0.007) and a lower warm-up rate before the matches compared to female players (p < 0.001).

CONCLUSIONS

Small-field tournaments in football have a high injury incidence. Male players have a higher injury incidence than female players and show additionally a lack of sleep and alcohol consumption the night before the tournament and poor warm-up performance on match day. Adequate preparation for a football tournament is the key factor for preventing injuries, also in recreational football.

Prevention of severe knee injuries in men's elite football by implementing specific training modules

PURPOSE

Injury prevention of knee injuries by means of training and warm-up exercises has been investigated in several studies in amateur football. However, the number of investigations in elite football is limited despite the currently higher injury incidence of severe knee injuries. Therefore, the purpose of this study was to investigate whether specifically adapted preventive training modules may reduce severe knee injuries in elite football.

METHODS

In a prospective controlled cohort study of elite football players in Germany, an injury prevention programme with 5 modules was implemented in the season of 2015-2016. The training modules were specifically adapted to this skill level and based on scientific evidence, team coach preferences, and the specific environment of this playing level. Of the 62 teams taking part in this study, 26 used the new trainings modules and 36 continued their standard programme as a control group. Success of the programme was documented by means of an injury report over one season. The primary outcome was reduction in severe knee injuries.

RESULTS

A pre-seasonal investigation had identified five modules to be implemented in the training routine. Postural stability, mobilisation of lower extremity joints, leg and trunk stabilisation, jumping, and landing exercises as well as agility movements were incorporated into the programme to prevent severe knee injuries in elite football. Over the season, the study group (529 players) with the adapted training modules had sustained 52 severe knee injuries (incidence: 0.38 per 1000 h football exposure; prevalence: 9.8%) compared to 108 severe knee injuries in the control group (601 players) using the standard programme (incidence: 0.68 per 1000 h football exposure; prevalence: 18.0%; p < 0.05). The overall injury incidence for any other type of injury was comparable between the two groups (3.3 vs. 3.4 in h 1000 football, n.s.).

CONCLUSION

Appropriate preventive training modules reduce severe knee injuries in elite football significantly. The key for the sustainability of preventive training measures are programmes specifically adapted to the demands of the playing level and to the preferences of the coaches LEVEL OF EVIDENCE: II.

["Stay and play" in football : Art of keeping players fit to play]

Many publications about the treatment and return to play after severe football injuries are available from the scientific literature, particularly about injuries requiring surgery. In contrast, less severe football injuries, such as muscle strains, ankle sprains and contusions, are less well addressed in the literature although these represent the most frequent type of injury. Additionally, such reports often have a low level of evidence and guidelines on treatment and the return to play process are very rare. Thus, the time away from football and the timing of return to play after minor injuries depends on the experience and skills of the responsible medical team. To achieve the aim of stay and play on the field, the medical team should be highly knowledgeable in interdisciplinary football medicine, prevention strategies, first aid on the field, clinical and manual diagnostics, tissue regeneration, symptomatic and conservative treatment as well as in return to play decision-making. No consensus exists on stay and play procedures neither on the practical level nor on the scientific level regarding injury definition, the diagnostic and treatment options and stay and play criteria. Therefore, this article presents the first steps for assessing stay and play strategies after minor injuries to standardize and improve practical routine, education and scientific research.

High return to competition rate following ACL injury - A 10-year media-based epidemiological injury study in men's professional football

Ruptures of the anterior cruciate ligament (ACL) typically occur in professional football and epidemiological data about longitudinal injury development is needed. This practice-driven investigation of media-derived ACL data provides information about professional football over 10 years. Injury registration was based on "kicker" sports magazine information that have been recorded over one decade in a standardized manner. Only ACL ruptures in the first German football league were included when they could be verified by a second reliable source. Level of evidence: III. Fifty-seven primary ACL ruptures were verified in the first German football league during the seasons 2007/2008 to 2016/2017. Among them, six re-injuries were found. Mean age at the time of injury was 24.8 years (SD 3.8). 31% (n = 20) of ACL ruptures occurred at the beginning of the season in August or September (p = 0.02). Mean time of RTC after primary ACL ruptures was 226.7 days (SD: 93.5) and 245.6 days (SD: 45.4) after re-injury. Although 62 (98%) players returned to football after injury and only one player immediately finished his career, 54.9% of the affected individuals played 3 years after the ACL rupture in the same league. ACL ruptures lead to longer absence than 7 months from football but does not give reason for immediate career-ending. The decrease in playing level after 3 years illustrate the serious consequences of ACL ruptures in football. Media-based injury reports may provide interesting information.

"What's my risk of sustaining an ACL injury while playing sports?" A systematic review with meta-analysis

OBJECTIVE

To estimate the incidence proportion (IP) and incidence rate (IR) for ACL injury in athletes.

DESIGN

Systematic review with meta-analysis DATA SOURCES: The PubMed, CINAHL and SPORTDiscus electronic databases were searched from inception to 20 January 2017.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies were included if they reported total number of participants/population by sex, total number of ACL injuries by sex and total person-time by sex.

RESULTS

Fifty-eight studies were included. The IP and IR of ACL injury in female athletes were 3.5% (1 out of every 29 athletes) and 1.5/10 000 athlete-exposures over a period of 1 season-25 years. The IP and IR of ACL injury in male athletes were 2.0% (1 out of every 50 athletes) and 0.9/10 000 athlete-exposures over a period of 1-25 years. Female athletes had a higher relative risk (RR) for ACL injury compared with males (RR=1.5; 95% CI 1.2 to 1.9; P<0.01) and a higher incidence rate ratio (IRR) of ACL injury compared with males over 1 season-25 years (IRR=1.7; 95% CI 1.4 to 2.2; P<0.010). When accounting for participation level, the disparity in the IR between female and male athletes was highest for amateur athletes compared with intermediate and elite athletes (IRR=2.1; 95% CI 1.3 to 3.4; P<0.01; I²=82%). Amateur female athletes remained at higher risk of ACL injury than did with amateur male athletes. In studies where follow-up length was <1 year, female athletes had a higher IR of ACL injury than did to males (IRR=1.7; 95% CI 1.3 to 2.2; P<0.01). Where follow-up was 1 year and beyond, there was no sex difference in the IR of ACL injury (IRR=2.1; 95% CI 0.9 to 4.8; P=0.06; I²=65%).

SUMMARY/CONCLUSIONS

One in 29 female athletes and 1 in 50 male athletes ruptured their ACL in a window that spanned from 1season to 25 years. The IR of ACL injury among female athletes in a season was 1.7 times higher than the IR of ACL injury among male athletes and the IP of ACL injury among female athletes was 1.5 times higher than the IP of ACL injury among male athletes. The reported sex disparity in ACL injury rates is independent of participation level and length of follow-up.

An Analysis of Knee Injuries in Rugby League: The Experience at the Newcastle Knights Professional Rugby League Team

Background

Epidemiologic data in professional sport is becoming an increasingly valuable tool in identifying frequently occurring injuries and developing strategies to reduce their occurrence. Currently, there is a paucity of literature on the epidemiology of knee injuries in professional male rugby league players.

Methods

We retrospectively reviewed medical records from a single male professional rugby league team (Newcastle Knights), competing in Australia, and evaluated knee injuries and time to return to play.

Results

In total, 89 knee injuries occurred, with an injury incidence of 616.7 injuries per 1000 players. The most frequently occurring knee injuries were medial collateral ligament (416.7 injuries per 1000 players) and chondral/meniscal injuries (416.7 injuries per 1000 players). For all injury types, being tackled was the most common mechanism of injury, and the median time to return to play was 1 day. Anterior cruciate ligament injuries accounted for the longest time to return to play (median 236.0 days).

Conclusion

Medial collateral ligament and chondral/meniscal injury types were the most frequent injuries; however, anterior cruciate ligament injuries accounted for the most time missed from sport despite being less common. Professional male rugby league players incur similar knee injury types compared to rugby union based upon our study and other similar studies.

Electronic supplementary material

The online version of this article (10.1186/s40798-019-0206-z) contains supplementary material, which is available to authorized users.

Epidemiology of Judo-Related Injuries in 21 Seasons of Competitions in France: A Prospective Study of Relevant Traumatic Injuries

BACKGROUND

Judo is a full-contact fighting sport that may lead to severe injuries. There are limited data available on the incidence of judo-related injuries. The French Judo Federation has established a surveillance system to document the frequency and type of injuries during judo competitions.

PURPOSE

To describe the incidence rates and types of judo-related traumatic injuries during 21 seasons of competitions in France with respect to athlete (judoka) age, sex, and level of performance.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

Between 1993 and 2014, each physician in charge of each judo competition filled out a form in which he/she documented the number of competing judokas, the number of fights, the number of medical interventions, the specific type of traumatic injuries for each intervention, the number of fight interruptions, and the number of athletes removed from the competition venue because of an injury. The age, sex, and level of performance of each judoka were also documented. Variance analysis was applied to assess whether differences in incidence rates of injuries between groups were significant (Student t test and chi-square test).

RESULTS

Surveillance of 421,670 fights demonstrated 3511 injuries in 316,203 judokas (incidence proportion, 1.1%). Among the injuries recorded, the most common were sprains (54.3%), fractures (15.6%), and dislocations (12.5%). Female athletes exhibited significantly higher incidence rates for knee sprains and elbow dislocations, whereas male athletes exhibited a higher incidence rate for shoulder dislocations (P < .001 for all). Regarding age, higher incidence rates were observed in young adults (aged 18-20 years) for acromioclavicular sprains and in children (aged 10-14 years) for clavicle fractures compared with adults (aged 21-35 years) (P < .001 for both). Both young adult and adult athletes had a higher incidence rate of shoulder dislocations (P < .001). Regarding the level of performance, athletes competing at higher levels had a higher incidence rate of sprains to the knee (P < .001).

CONCLUSION

During 21 years of surveillance of injuries in judo competitions in France, the incidence proportion of injuries was 1.1%. Significant differences in incidence rates demonstrated when considering age, sex, and level of performance may help in developing strategies to prevent traumatic injuries in the future.

Anterior cruciate ligament injury risk factors in football

INTRODUCTION

Anterior cruciate ligament (ACL) lesion represents one of the most dramatic injuries in a football (soccer) player's career. There are many injury risk factors related to intrinsic (non-modifiable) and/or extrinsic (modifiable) factors of ACL injury.

EVIDENCE ACQUISITION

Research of the studies was conducted until September 2018 without publication data limitation or language restriction on the following databases: PubMed/MEDLINE, Scopus, ISI, EXCERPTA.

EVIDENCE SYNTHESIS

To date, evidence from the literature suggests that the risk of ACL injury is multifactorial and involves biomechanical, anatomical, hormonal, and neuromuscular factors. Despite this relative complexity, the mechanisms of injury are well known and rationally classified into two categories: mechanisms of injury based on contact or on non-contact with another player, with the non-contact injury mechanisms clearly prevailing over the mechanisms of contact injury. One of the most frequent biomechanical risk factors, associated with ACL non-contact injury, is represented by the valgus knee in the pivoting and cutting movements and in the landing phase after jumping. Gender-related risk factors show female populations to have a higher predisposition to ACL injury than males However, there are still some theoretical and practical aspects that need further investigation such as; genetic risks together with the role of estrogen and progesterone receptors in female populations, and the in-vivo interaction shoe-playing surface. In particular, the genetic risk factors of ACL lesion seem to be an interesting and promising field of investigation, where considerable progress has still to be made.

CONCLUSIONS

This narrative review provides an insight into the risk factors of ACL injury that could be used by practitioners for preventing injury in football (soccer).

Anterior Cruciate Ligament Injury Risk in Sport: A Systematic Review and Meta-Analysis of Injury Incidence by Sex and Sport Classification

OBJECTIVE

To evaluate sex differences in incidence rates (IRs) of anterior cruciate ligament (ACL) injury by sport type (collision, contact, limited contact, and noncontact).

DATA SOURCES

A systematic review was performed using the electronic databases PubMed (1969-January 20, 2017) and EBSCOhost (CINAHL, SPORTDiscus; 1969-January 20, 2017) and the search terms anterior cruciate ligament AND injury AND (incidence OR prevalence OR epidemiology).

STUDY SELECTION

Studies were included if they provided the number of ACL injuries and the number of athlete-exposures (AEs) by sex or enough information to allow the number of ACL injuries by sex to be calculated. Studies were excluded if they were analyses of previously reported data or were not written in English.

DATA EXTRACTION

Data on sport classification, number of ACL injuries by sex, person-time in AEs for each sex, year of publication, sport, sport type, and level of play were extracted for analysis.

DATA SYNTHESIS

We conducted IR and IR ratio (IRR) meta-analyses, weighted for study size and calculated. Female and male athletes had similar ACL injury IRs for the following sport types: collision (2.10/10 000 versus 1.12/10 000 AEs, IRR = 1.14, P = .63), limited contact (0.71/10 000 versus 0.29/10 000 AEs, IRR = 1.21, P = .77), and noncontact (0.36/10 000 versus 0.21/10 000 AEs, IRR = 1.49, P = .22) sports. For contact sports, female athletes had a greater risk of injury than male athletes did (1.88/10 000 versus 0.87/10 000 AEs, IRR = 3.00, P < .001). Gymnastics and obstacle-course races were outliers with respect to IR, so we created a sport category of fixed-object, high-impact rotational landing (HIRL). For this sport type, female athletes had a greater risk of ACL injury than male athletes did (4.80/10 000 versus 1.75/10 000 AEs, IRR = 5.51, P < .001), and the overall IRs of ACL injury were greater than all IRs in all other sport categories.

CONCLUSIONS

Fixed-object HIRL sports had the highest IRs of ACL injury for both sexes. Female athletes were at greater risk of ACL injury than male athletes in contact and fixed-object HIRL sports.

Injury incidence in semi-professional football claims for increased need of injury prevention in elite junior football

PURPOSE

Injuries are a common occurrence in football. Sufficient epidemiological data are available in professional football but not in salaried semi-professional football. This study investigates the injury incidence at different levels of semi-professional football with focus on junior football.

METHODS

The data were based on injury reports provided by players and medical staff over the 2015-2016 season, which corresponded to the consensus statement for data samples in football. This study investigated the injury incidence and prevalence of five skill levels of semi-professional football (the fourth to the seventh league and elite junior football).

RESULTS

1130 players had sustained 2630 injuries over the 2015-2016 season. The overall injury incidence was 9.7 per 1000 h football exposure; prevalence with at least one injury was 79%. The highest overall injury incidence in elite junior football was 10.4 in 1000 h football exposure. The fifth league had the lowest incidence with 9.0 in 1000 h football (p < 0.05). Traumatic injuries most often occurred in the fourth league (3.9 in 1000 h football). The body areas most affected by traumatic injury were knees, ankles and thighs. Elite junior players had a significantly higher incidence of overuse complaints (7.4 in 1000 h football) than the fourth league (5.4, p = 0.005). The body areas most affected by overuse complaints were the lower back, thigh and groin. No differences were found between the different positions on field.

CONCLUSIONS

Salaried semi-professional football involves a high overall injury incidence. The highest incidence, particularly of overuse injuries, was seen in elite junior football. These findings should be incorporated in specific injury prevention training or screenings beginning in junior football. Level of evidence II.

Contact times of change-of-direction manoeuvres are influenced by age and the type of sports: a novel protocol using the SpeedCourt® system

PURPOSE

Side-to-side asymmetry in side-cutting manoeuvres is a known risk factor for severe knee injury. Potential leg asymmetry during ground contact times of different change-of-direction manoeuvres was evaluated in athletes by means of the recently developed SpeedCourt^® system. The hypotheses were that ground contact times and the limb symmetry index are affected by age and the type of sports.

METHODS

One-hundred and sixty-five athletes (149 men, 16 women, age 16.5 ± 5.1) of popular team sports such as football, team handball and baseball were assessed by means of three different tests [side-hop, lateral change-of-direction (COD) and diagonal COD] using the SpeedCourt^® system. Analysis included the factors age, sex, type of sports, ground contact time, leg symmetry index and limb dominance.

RESULTS

During lateral but not diagonal COD tests, football players had shorter contact times than players of team handball (p = 0.026) and baseball (p = 0.015) of the same age group. The side-hop tests yielded differences in the leg symmetry index between players < 16 years and players > 16 years (p < 0.01). Mean ground contact time differed in each of the side-hop, lateral COD and diagonal COD tests (143.5 ± 20.0 vs. 256.2 ± 66.1 vs. 320.4 ± 55.0). Contact times and test durations of side-hop, lateral COD and diagonal COD tests were shorter for older players (p < 0.01).

CONCLUSIONS

Ground contact times of side-hop and change-of-direction manoeuvres are influenced by age, the type of sports and limb dominance. Such information is fundamental for future sports medicine research and needs to be considered in pre-season screening or when used as a criterion for return-to-competition of players with previous severe knee injury. Assessment of change-of-direction manoeuvres should be included in future return-to-competition test batteries.

LEVEL OF EVIDENCE

III.

Beach handball is safer than indoor team handball: injury rates during the 2017 European Beach Handball Championships

PURPOSE

Beach handball is a relatively new type of sports, which was derived from team handball. Medical issues such as frequency and severity of injury are yet unknown. The purpose of this study was to investigate the injury pattern and injury rates of this new type of sports.

METHODS

This study investigated the injury incidence of 30 national teams (10 senior and 20 u-17 teams, 16 men's and 14 women's teams) participating in the 2017 European Beach Handball Championships. Reports on injuries sustained during the senior and u-17 youth tournaments were provided by the medical staff of each team. Injury incidence was differentiated between age and sex, and between the five field positions (goalkeeper, wing, central defender, pivot, and specialist).

RESULTS

During the tournaments, 87 injuries were recorded yielding an overall injury incidence of 286.1 per 1000 match hours. Time-loss due to injury was 49.3 per 1000 match hours. Senior players had a higher overall injury incidence with 395.3 injuries than u-17 players with 205.7 injuries per 1000 h match hours (p < 0.01). Comparison of the injury incidence between the two sexes showed 330.23 injuries per 1000 h handball exposure for male players and 234.9 injuries for female players (n.s.). The most frequent injury type was sprains (21 injuries, 24.1%) followed by contusions (19 injuries, 21.8%) and skin abrasions with (15 injuries, 17.2%). Central defenders and specialists had the highest injury incidence. Thighs, ankles, as well as foot and toes (altogether 12 injuries, all 13.8%) were the three most frequently injured anatomic sites.

CONCLUSIONS

Beach handball seems to have a lower incidence of time-loss injuries than that reported for indoor team handball. This study is an important basis for developing injury prevention strategies in this sports that should focus on thighs, ankles, feet and toes. Further research into this new type of sports is essential to identify risk factors and to develop adequate injury prevention measures.

LEVEL OF EVIDENCE

II.

Injury prevention and return to play strategies in elite football: no consent between players and team coaches

INTRODUCTION

Injuries are a common problem in football. To improve prevention strategies, the players' (p) and coaches' (c) views need to be disclosed as they have a strong impact on return to play decisions. The aim of this study is to reveal current opinions with regard to injury prevention and return to play strategies to introduce new strategies in elite football.

MATERIALS AND METHODS

In a retrospective data analysis of elite salaried football players (n = 486) and team coaches (n = 88), a detailed investigation by means of a standardized questionnaire was carried out. In a preseason period of the 2015/16 season and as part of a large interventional research project in elite salaried German football, a request about players' and team coaches' knowledge and opinions was performed. Topics such as injury prevention, return to play after injuries, the importance of screening tests, general problems of injuries in football, or the decision-making in terms of prevention and return to play in elite football were investigated.

RESULTS

The study revealed a high interest in injury prevention and screening tests among players and coaches (p 82.5%; c 99.1%). The participants of the study reported warm-up exercises (p 76.4%; c 74.7%), regeneration training (p 54.1%; c 56.3%), and core stability (p 53.8; c 70.1%) as the most important prevention methods, but the additional investigation of the teams' current daily training routine showed that the transfer is incomplete. Coaches are more familiar with scientific published warm-up programs like FIFA 11 + than players (42.5 vs. 12.6; p < 0.001). Knee injuries (p 90.7%; c 93.1%) and ACL injuries in particular were reported as the most severe and common problem in elite football. Players and coaches expressed different attitudes concerning return to play decisions. While players want to decide themselves (81.4%), team coaches consult medical advice ahead of the decision of return to play after injuries (83.5%; p < 0.001). Decisions against the doctor's recommendation are often made by both groups (p 64.4% vs. c 87.1%; p < 0.001).

CONCLUSION

The basic knowledge of prevention and injuries is sufficient in elite football, but the transfer from theoretical knowledge to practical routine is suboptimal. The study also shows possibilities to improve the prevention process and communication between players, coaches, doctors, and physiotherapists, while there is no consent between players and coaches regarding return to play decision.

Increased injury rates after the restructure of Germany's national second league of team handball

PURPOSE

Scientific injury data in men's professional team handball injuries are rare and even less scientific information exists on injury prevention. In 2011, Germany's national second team handball league was restructured by merging the existing two regional leagues into one league. This study evaluates the injury patterns in professional team handball and compares the injury rates between the first and second league before and after the restructure.

METHODS

All players of Germany's national first and second men's team handball leagues have mandatory trauma insurance with the same insurance company. This retrospective cohort study analysed the injury data of three consecutive seasons 2010-2013 using standardized injury definitions.

RESULTS

1194 professional team handball players were included in this study. The majority of severe injuries affected the lower extremities, shoulders, and hands. The average injury incidence significantly differed between the first (4.9 injuries per 1000 h) and the second league (3.9 per 1000 h, p < 0.01). The injury incidence in the restructured second league had increased from 3.7 to 4.1 per 1000 h (p < 0.01) and prevalence from 67.1 to 79.3% (p < 0.001), thus almost to the same levels of the first league. The second league showed more time-loss injuries at all severity levels.

CONCLUSION

This study yielded a high injury incidence after the restructure of the national second team handball league and presents details on prevalence, incidence, and patterns of injury in professional men's team handball. This study is an important basis for developing injury prevention strategies that should focus on the shoulders, hands, and lower extremities and on reducing the number of matches and travel burden.

LEVEL OF EVIDENCE

III.

Neuromuscular exercises prevent severe knee injury in adolescent team handball players

PURPOSE

Team handball is associated with a high risk of severe knee injury that needs to be reduced, particularly at the youth level. The purpose of this study was to show how an injury-prevention programme effectively reduces severe knee injury in adolescent team handball players.

METHODS

Of 23 adolescent handball teams of both sexes, 13 were randomly allocated into the intervention group (168 players) and 10 into the control group (111 players). Players of the intervention group regularly participated in an injury-prevention programme for one season. Handball exposure and sustained injuries were documented for both groups on a monthly basis. The primary outcome parameter of the injury-prevention programme was the incidence of severe knee injury.

RESULTS

Of the 279 included players, 68 (24%) sustained 82 injuries yielding an overall incidence of 1.85 injuries per 1000 h handball exposure (intervention group: 50 injuries/incidence: 1.90/1000 h; control group: 32 injuries/incidence: 1.78/1000 h). Knee injury was the second most frequent injury in adolescent team handball. The primary outcome parameter, severe knee injury occurred significantly more often in the control group [mean age (SD) 15.1 (1.0), injury incidence 0.33/1000 h] than in the intervention group [mean age (SD) 14.9 (0.9), injury incidence 0.04/1000 h]. The odds ratio was 0.11 (95% CI 0.01-0.90), p = 0.019. Other injuries to the lower extremities showed no significant difference between the two groups.

CONCLUSIONS

Frequent neuromuscular exercises prevent severe knee injury in adolescent team handball players and should thus be included in the practical routine as well as in the education of team coaches.

Injury mechanism of midfacial fractures in football causes in over 40% typical neurological symptoms of minor brain injuries

PURPOSE

The injury mechanisms of midfacial fractures may be typical causes of concussion, but hardly any scientific data on midfacial injuries sustained in football are available. Head and brain trauma represent frequent injuries in athletes of different sports that require appropriate treatment by sports and trauma physicians. This study investigated the management of midfacial fractures in football and the association of such fractures with concomitant brain injury.

METHODS

In a prospective cohort study lasting 24 months (2012 to 2013), midfacial injuries of football players were analysed with regard to the injury mechanisms, first aid procedures on the field, treatment and return-to-play. To analyse concomitant and potentially overlooked minor brain injuries due to the trauma, we retrospectively investigated the neurological symptoms of the study population.

RESULTS

The study included 132 football players (37 semi-professionals and 95 amateurs) with midfacial fractures. The main injury mechanisms were head-to-head and head-to-elbow trauma. The mean period of return-to-play after trauma was 33.5 days, which was significantly shortened if a protective face mask was worn (mean 10.4 days earlier, p = 0.0006). Semi-professional football players returned to play earlier (p = 0.009) and more often used protective face masks (p = 0.001). 55 players (41.6%) had neurological symptoms immediately after trauma as a possible sign of concomitant minor brain injury. 5 of 132 players with concussion had been hospitalised for 24 h, but no persistent neurological symptoms were detected.

CONCLUSION

In football, midfacial fractures represent moderate-to-severe injuries with time away from sports of more than 4 weeks. Over 40% of athletes with a midfacial fracture showed concomitant neurological symptoms as a sign of minor brain injury. Therefore, sports physicians and other staff supervising athletes in daily practice should be aware of the presence of neurological symptoms.

LEVEL OF EVIDENCE

Level III.

'What's my risk of sustaining an ACL injury while playing football (soccer)?' A systematic review with meta-analysis

OBJECTIVE

To estimate the incidence proportion (IP) and incidence rate (IR) of ACL injury in football players.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

PubMed, CINAHL and SPORTDiscus electronic databases were searched from inception to 20 January 2017.

ELIGIBILITY CRITERIA FOR SELECTING STUDY

Studies that reported the total number of participants/population by sex, total number of ACL injuries by sex and total person-time by sex were included.

RESULTS

Twenty-eight studies were included. The IP and IR of ACL injury in female football players were 2.0% (95% CI 1.2% to 3.1%) and 2.0/10 000 athlete exposures (AEs) (95% CI 1.6 to 2.6; I²=91%) over a period of one season to 4 years. The IP and IR of ACL injury in male players were 3.5% (95% CI 0.7% to 8.2%) and 0.9/10 000 AEs (95% CI 0.7 to 1.1; I²=94%). Studies that evaluated matched cohorts of female and male players showed no difference in IP (relative risk=1.2; 95% CI 0.9 to 1.6; P=0.47) over a period of one season to 4 years. Women were at greater risk than men (incidence rate ratio (IRR)=2.2; 95% CI 1.6 to 3.1; I²=83%; P<0.001). When accounting for participation level, the difference in IR between women and men was greatest for intermediate players (IRR=2.9; 95% CI 2.4 to 3.6) compared with amateur (IRR=2.6; 95% CI 1.4 to 4.8) and elite (IRR=2.0; 95% CI 1.1 to 3.4) players.

SUMMARY/CONCLUSION

Overall, more men sustained ACL injury in football. There was no difference in the relative risk of ACL injury between female and male football players in a window that spanned one season to 4 years. The IR of ACL injury among women was 2.2 times higher than the IR of ACL injury among men. The reported sex disparity in ACL injury was independent of participation level.

Anterior cruciate ligament ruptures in German elite soccer players: Epidemiology, mechanisms, and return to play

BACKGROUND

Anterior cruciate ligament ruptures (ACLRs) are severe sports-related injuries with significant consequences for affected players and teams. This study aims to identify the epidemiology and injury-related lay-off after ACLR in professional male soccer players from the first-division German Bundesliga.

METHODS

Exposure times and incidence of anterior cruciate ligament ruptures were collected during 7.5 consecutive seasons using two media-based registers.

RESULTS

A total of 72 total ACLRs were registered in 66 different players with an incidence of 0.040 per 1000h of exposure (95% CI 0.009-0.12). On average there were 9.6 ACLRs per season and 0.53 per team and season. The mean age of players affected was 24 (standard deviation±3.6) years. The number of ACLRs recorded per season fluctuated during the period observed. Goalkeepers are significantly (P<0.05) less prone to suffer an ACLR compared to outfield players.

CONCLUSIONS

Understanding ACLR loading mechanisms, knowing risk factors for the injury and mean off time after ACLR are essential information for the coach, the medical staff, the elite soccer players, the insurance and team managers. Our results are in accordance with reports based on information from medical team staff. Therefore, our analysis of ACLR based on media sources may serve as an alternative for injury reports in elite soccer. The information of this study may be helpful for the medical staff taking care of professional soccer players and for orthopedic surgeons performing ACL reconstructions in this patient population.