Injuries in Modern Football and the Need for Strong Foundations
Authored by Greg King
There is little doubt that some injuries are increasing in frequency and severity in elite football.
It has been reported, in elite men’s football that injury incidence is 8.1 injuries per 1000 hours of exposure (~1 injury per week)
Injuries most commonly occur in the lower limb muscle/tendon area. 4.6 injuries per 1000 hours of training exposure (>1 injury every 2 weeks)
Injury incidence is 10 times higher during competitive matches than during training (6).
Concerning? Yes. An important factor for our training program? Certainly! However, before we throw the old program in the bin and follow the next loudest guru, it’s important to look a little more deeply into what the (good) evidence suggests.
The objective of this article is to assist you to further develop your filter for what is relevant and important on this issue. Additionally, to encourage coaches to continue to develop your program based on the game model and your specific training environment.
Hamstring muscle injuries (including semi-membranosus and semi-tendinosus but predominantly biceps-femoris) are the chief protagonist. In elite men’s football, they have increased from 12% of total injury incidence in 2001 to 24% in 2022 (4).
It is hard to confirm whether injuries of the anterior cruciate ligament of the knee (ACL) have also been increasing. ACL injuries make up approximately 1.42% of all injuries in elite men’s football (7). However, as we know, injuries of the ACL can cost a player and a team around 9 months of intensive rehab time. Interestingly ACL injuries make up ~2% of all injuries in elite women’s football (5) and >2.5% in elite youth football (17-20 year olds). They even occur in U13 elite football (1).
Both hamstring and ACL injuries are highly preventable.
Research from Germany demonstrated that semi-professional and amateur football athletes are more likely to suffer from an ACL injury than a professional athlete. In fact, the lower the level of football, the higher the risk (9). Potentially indicating, that the level of detail in the training program is a more important factor than the intensity of the competition.
You might be surprised to find out, that ‘overall injury incidence’ has not increased over the past 20 years in men’s elite football (4). The usual suspects of quadriceps, adductor and calf injuries, have all remained steady through this time-period. Considering the likely (for most people obvious) increase in power, explosiveness and repetition of football actions, in modern football, there is plenty of evidence to suggest that our physical performance & injury mitigation strategies have more good than bad.
I truly believe that the best of modern sport science has brought about huge gains in professionalism, recovery, nutrition, mental preparation, strength training, periodization and planning. However modern sport science also has its limitations and coaches of all levels, have their limitations in implementing the appropriate science.
What we need now, as much as ever, is to be incredibly discerning in the information we use to create our training programs. To use the magnificent work of our best football science researchers and to learn from the many years of planning and periodization of highly successful coaches.
There has been a stack of quality research in the past 5 years, which is fantastic news for those hungry to learn and evolve. However, with this, comes an even greater list of ‘evidence-based methods’ that we feel need to be included in our program. This, right here, is where we need to be careful.
Be very clear with what is essential in your program and additionally, what is the foundation of your program and what elements are needed to support the foundation.
My Foundations for Injury Mitigation
Have a very clear idea of how the team is going to play and what this looks like and feels like across a 90 minute match. If you don’t have any input into how the team is going to play, it is just as vital to understand what this looks and feels like, physically.
An on-field training program that intelligently progresses the athletes towards the key objective mentioned above.
Ensuring regular exposure to intensities at or above the intensity of the match. Using exercises that simulate the game style and principles of the team.
Planning for high relative training loads in the pre-season and early-season phase. From experience and regular discussion, with other experts in the field, getting this right, is likely the highest priority aspect of reducing injury risk during the competition phase of the season. There is also some excellent research on this topic (2,3,8).
Ensuring enough recovery time between the match or the exposures to high intensity training and the next match.
Include in the program the best possible, complimentary training methods to support the key objectives mentioned above. The following areas have been proven, beyond doubt, to support a high intensity training program:
Appropriate nutritional intake
Appropriate sleep time and quality
Appropriate hydration
Strength training
Train hard and smart!
Recommended Reading
Ekstrand et al. 2022 paper on injury incidence across multiple UEFA seasons.
Buchheit et al. 2024 paper on modern periodization
References
Astur, D.C., Margato, G.F., Zobiole, A. et al. The incidence of anterior cruciate ligament injury in youth and male soccer athletes: an evaluation of 17,108 players over two consecutive seasons with an age-based sub-analysis. Knee Surg Sports Traumatol Arthrosc31, 2556–2562 (2023). https://doi.org/10.1007/s00167-023-07331-0
Colby, Marcus J.1,2; Dawson, Brian1,2; Heasman, Jarryd2; Rogalski, Brent2; Rosenberg, Michael1; Lester, Leanne1; Peeling, Peter1. Preseason Workload Volume and High-Risk Periods for Noncontact Injury Across Multiple Australian Football League Seasons.
Ekstrand J, Spreco A, Windt J, Khan KM. Are Elite Soccer Teams' Preseason Training Sessions Associated With Fewer In-Season Injuries? A 15-Year Analysis From the Union of European Football Associations (UEFA) Elite Club Injury Study. Am J Sports Med. 2020 Mar;48(3):723-729. doi: 10.1177/0363546519899359. Epub 2020 Jan 28. PMID: 31990574.
Ekstrand J, Bengtsson H, Waldén M, Davison M, Khan KM, Hägglund M. Hamstring injury rates have increased during recent seasons and now constitute 24% of all injuries in men's professional football: the UEFA Elite Club Injury Study from 2001/02 to 2021/22. Br J Sports Med. 2022 Dec 6;57(5):292–8. doi: 10.1136/bjsports-2021-105407. Epub ahead of print. PMID: 36588400; PMCID: PMC9985757.
HallÃn A, Tomás R, Ekstrand J, et al. UEFA Womens Elite Club Injury Study: a prospective study on 1527 injuries over four consecutive seasons 2018/2019 to 2021/2022 reveals thigh muscle injuries to be most common and ACL injuries most burdensome. British Journal of Sports Medicine 2024;58:128-136.
López-Valenciano A, Ruiz-Pérez I, Garcia-Gómez A, Vera-Garcia FJ, De Ste Croix M, Myer GD, Ayala F. Epidemiology of injuries in professional football: a systematic review and meta-analysis. Br J Sports Med. 2020 Jun;54(12):711-718. doi: 10.1136/bjsports-2018-099577. Epub 2019 Jun 6. PMID: 31171515; PMCID: PMC9929604.
Mazza D, Viglietta E, Monaco E, Iorio R, Marzilli F, Princi G, Massafra C, Ferretti A. Impact of Anterior Cruciate Ligament Injury on European Professional Soccer Players. Orthop J Sports Med. 2022 Feb 22;10(2):23259671221076865. doi: 10.1177/23259671221076865. PMID: 35224121; PMCID: PMC8873562.
Murray NB, Gabbett TJ, Townshend AD. Relationship Between Preseason Training Load and In-Season Availability in Elite Australian Football Players. Int J Sports Physiol Perform. 2017 Jul;12(6):749-755. doi: 10.1123/ijspp.2015-0806. Epub 2016 Nov 11. PMID: 27834571.
Szymski D, Achenbach L, Zellner J, Weber J, Koch M, Zeman F, Huppertz G, Pfeifer C, Alt V, Krutsch W. Higher risk of ACL rupture in amateur football compared to professional football: 5-year results of the 'Anterior cruciate ligament-registry in German football'. Knee Surg Sports Traumatol Arthrosc. 2022 May;30(5):1776-1785. doi: 10.1007/s00167-021-06737-y. Epub 2021 Sep 15. PMID: 34524500; PMCID: PMC9033691.