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The previous three Women World Cup tournaments show a clear trend of a steady increase in the mean number of injuries per match. This trend found in the women's game is in contrast with the trend observed in the men's game, where player injuries have decreased overall.

Is it all a mere coincidence, or is there an explanation for the increase in injuries in women's football? These are questions which FIFPro and its Chief Medical Officer, Dr. Vincent Gouttebarge, would like to have answered. In his new blog, he views injuries in women's professional football through a scientific lens.

Key points

  • Played by 26 million people worldwide (4.1 million registered), women's football obtained professional status at the beginning of the Twenty-First century and is today represented by specific committees at both FIFA and FIFPro.
  • Contrasting prevailing trends in male professional football, the mean number of injuries per match suffered by female players during previous FIFA World Cups has increased from 1.7 injury per match in 2003 to 2.3 in 2011.
  • During previous international tournaments (World Cups, Olympic Games, Youth Championships), nearly 75% of injuries occurred as a consequence of contact activities, with lower extremities (ankle, thigh and knee) being the most affected region.
  • All six venues selected for the upcoming World Cup 2015 in Canada are laid with artificial turf. Playing on artificial turf does not lead to a higher risk of injury, but can (will!) create negative influence on performance and negative perception of players.
  • In the upcoming years, FIFPro will strive to challenge issues in female professional football such as minimum medical standards, medical support, pre-competition medical examinations and environmental conditions.

 

Today, women's football has experienced exponential growth in the popularity of the sport. Worldwide, football is the most prevalent team sport played by women, with a 50% increase of the amount of players participating between 2000 and 2006. FIFA estimates that 30 million women play football around the globe, from which 4.8 million are registered by a national federation (FIFA 2014).

At the beginning of the 21st century, women's professional football was introduced and has been developing strongly since, leading to the creation of dedicated committees at FIFA and more recently at FIFPro. Nevertheless, as in other professional sport disciplines, women's professional football does not possess the same recognition as the men's professional game, struggling especially with gender equality, communications, labour contracts and payment. However, both male and female professional footballers share in common the occurrence and recurrence of musculoskeletal injuries (bones, muscles, tendons, joints, ligaments).

Injury occurrence during international tournaments

The first Women's football World Cup (WWC) was held in 1991 in Chinaand a tournament for women's football has been included in the Olympic Games (OG) since 1996. Since these first steps, FIFA has also introduced a U-17, U-19 and U-20 World Championships for women. Similar to male players, FIFA reports during several international tournaments have shownthat female players are at risk for injury of the musculoskeletal system (bones, muscles, tendons, joints, ligaments). During these events, team physicians of all participating nations were asked to record and report all injuries suffered by their players during each match. As shown in figure 1, the mean number of injuries per match during the FIFA World Cups increased from 1.7 injury per match in 2003 to 2.3 in 2011 (FIFA 2011). Regarding injuries which led to a loss of competition time ,the same trend was found, namely an increase from 0.7 injuries per match in 2003 to 1.1 in 2011.

FIFA reported that 80% of these injuries were contact injuries, of which approximately 50% were caused by foul play (FIFA 2011). About 75% of the injuries occurred in the lower extremities, with the lower legs and ankle joints being the most common location (FIFA 2011). The same trend was observed during other international competitions, particularly the Olympic Games (Figure 1): the mean number of injuries per match increased from 2.1 injuries per match in 2000 to 2.9 in 2008. By contrast, the number of injuries per match during the male World Cups decreased from 2.7 in 2002 to 1.7 in 2014 (Junge 2015).

Figure 1: Injury occurrence in international tournaments (FIFA 2011)

VG Figure 1 Women injuries 550

 

In 2007, Junge and colleagues published a scientific paper analyzing the injury occurrence during 184 matches played at seven international tournaments (1999 and 2003 WC; 2000 and 2004 OG; 2002 and 2004 U-19 WC; 2006 U-20 WC). A total of 387 injuries were reported (equivalent of 2.2 injuries per match), from which only 16% derived from non contact activities (Junge 2007). The lower extremities were the most affected (65%), followed by head and neck (18%), trunk (9%) and upper extremities (8%). Distribution in term of body parts was: ankle (24%), head (16%), thigh (12%), knee (11%) and lower leg (11%). Most of the injuries were contusions (45%), sprains or ligament ruptures (26%) and strains or muscle fiber ruptures (8%) (Junge 2007). The number and mechanism of injuries in relation to time in the match can be found in figure 2. In 2007, Tscholl and colleagues published a similar scientific study analyzing the injury occurrence during six international tournaments (1999 and 2003 WC; 2000 and 2004 OG; 2002 and 2004 U-19 WC). The authors analyzed 142 matches and reported the occurrence of 293 injuries (equivalent of nearly 2.1 injuries per match), from which 14% aroused from non contact activities (Tscholl 2007). From all contact injuries, 20% affected the head and neck, 19% the ankle joints and 13% the thighs (Tscholl 2007).

Figure 2: Injury occurrence in relation to time in the match (Junge 2007)

VG Figure 2 Women injuries 550

Injury occurrence in national competitions

In contrast to men's professional football, there is little research directed towards the injury occurrence among female players during national (domestic) competitions. In a study over two seasons in the Women's United Soccer Association (USA), Giza and colleagues (2005) reported a total of 173 injuries occurred in 202 players from eight teams (93 injuries during the first season and 80 during the second). The most common location was the knee (32%), followed by the head (10%), ankle (9%) and foot (9%). Tegnander and colleagues (2008) studied over one season the injury rate of 181 female players from the elite division in Norway. A total of 189 injuries were recorded, affecting 52% of the players included in the study (Tegnander 2008). The authors found that 47% of these injuries occurred during matches and 53% during training sessions. The majority of the injuries occurred in the lower extremities (81%), the most common location being the ankle, knee and thigh (Tegnander 2008).

Recently, Professional Footballers Australia (PFA, the Australian players' association) has launched its first report on the occurrence of injuries during the 2013/2014 W-League. A total of 42 injuries were observed, of which knee joints were the most affected (26%). The total number of games missed as a consequence of injuries was 154, leading to an average of around 3.5 games missed per injury.

Is artificial turf a cause for injury occurrence?

Several studies have studied which factors cause the occurrence of injuries in women's professional football. Among others, an age over 25 years old, a greater body mass index (BMI) and an increased general joint laxity were found to be associated with a new lower extremity injury (especially thigh) in Norwegian and Swedish elite female players (Ostenberg 2000; Nilstad 2014). Another cause of injury in women professional football has been assumed to be the playing surface on which many female players often train and compete: artificial turf. The discussion about artificial turf has become even more relevant in recent times as all six venues from the upcoming World Cup 2015 in Canada use artificial turf.

Information gathered from the scientific literature shows that the assumption that artificial turf increases the injury risk compared to natural grass is not grounded. In a study of Ekstrand and colleagues (2011) involving 20 elite teams (15 male, 5 female) from several European countries playing home matches on third generation artificial turf, there was no significant difference found in the injury rates of artificial turf and natural grass. The same finding was found in youth male and female footballers in Norway (Soligard 2012).

In contrast to the lack of evidence that artificial turf induces a greater injury risk when compared to natural grass, both performance and players' perception are not favourable to artificial turf. Among professional footballers, 50 to 90% of players surveyed in Germany, The Netherlands and Slovenia felt that artificial turf was reducing the quality of the game, while 75% of the professional players from the Swedish premier league had negative attitude towards playing competition games on artificial turf (Andersson 2007; Johansson 2007).

Women injury 640

 

FIFPro's challenge in women's professional football

FIFPro, the voice of all professional players worldwide,advocates the equality of all professional footballers across continents and countries, regardless of race, religion or gender.FIFPro will strive through its Women's Football Committee to tackle some of the issues that a great majority of female players face while doing their daily work on the field, such as gender inequality, communications, labour contracts and payment.

When it comes to health and safety, challenging dialogues should be engaged on issues such as:

  • implementing minimum medical standards in women's football as a part of Collective Bargaining Agreement;
  • sufficient and qualified medical support available in each professional football club;
  • pre-competition medical examinations in order to screen for any relevant medical condition;
  • monitoring the environmental conditions in which female players train and compete, especially the switches from grass to artificial turf that often occur.

 

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