Accepted: 13 February 2017

DOI: 10.1111/sms.12860

ORIGINAL ARTICLE

A comparison of injuries in elite male and female football

players: A five-­season prospective study

J. Larruskain1   |  J. A. Lekue2,3  |  N. Diaz2  |  A. Odriozola1  |  S. M. Gil3

1
Department of Genetics, Physical
Anthropology and Animal
Physiology, Faculty of Science and
Technology, University of the Basque
Country (UPV/EHU), Leioa, Spain
2
Medical Services, Athletic Club, Lezama,
Spain
3
Department of Physiology, Faculty of
Medicine and Nursing, University of the
Basque Country (UPV/EHU), Leioa, Spain
Correspondence
Susana M. Gil, Department of Physiology,
Faculty of Medicine and Nursing,
University of the Basque Country (UPV/
EHU), Leioa, Spain.
Email: susana.gil@ehu.eus
Funding information
Vice-Chancellorship for Basque of the
University of the Basque Country UPV/
EHU (Euskararen arloko Errektoreordetza)
The aim was to compare the epidemiology of injuries between elite male and female
football players from the same club. Injuries and individual exposure time in a male
team and a female team, both playing in the Spanish first division, were prospec-
tively recorded by the club’s medical staff for five seasons (2010-­2015) following
the FIFA consensus statement. Total, training, and match exposure hours per player-­
season were 20% higher for men compared to women (P<.01). Total, training, and
match injury incidence were 30%-­40% higher in men (P≤.04) mainly due to a 4.82
(95% confidence interval [CI] 2.30-­10.08) times higher incidence of contusions, as
there were no differences in the incidence of muscle and joint/ligament injuries
(P≥.44). The total number of absence days was 21% larger in women owing to a 5.36
(95% CI 1.11-­25.79) times higher incidence of severe knee and ankle ligament inju-
ries. Hamstring strains and pubalgia cases were 1.93 (95% CI 1.16-­3.20) and 11.10
(95% CI 1.48-­83.44) times more frequent in men, respectively; whereas quadriceps
strains, anterior cruciate ligament ruptures, and ankle syndesmosis injuries were 2.25
(95% CI 1.22-­4.17), 4.59 (95% CI 0.93-­22.76), and 5.36 (95% CI 1.11-­25.79) times
more common in women, respectively. In conclusion, prevention strategies should
be tailored to the needs of male and female football players, with men more predis-
posed to hamstring strains and hip/groin injuries, and women to quadriceps strains
and severe knee and ankle ligament injuries.

KEYWORDS
man, sex, soccer, woman

1  |   IN T RO D U C T ION compared the injury epidemiology between male and female

Football offers multiple physiological and psychosocial
benefits, but unfortunately the risk of injury is also high.1
Injuries negatively impact team performance2 and economy3
and might have long-­term health consequences affecting the
quality of life of players.4 Therefore, preventing injuries is a
priority in football.
The first step in injury prevention is to describe the ep-
idemiology of injuries,5 and while the literature on male
players is extensive,6 evidence in female players is scarce7,8
and mainly focused on anterior cruciate ligament (ACL)
injuries.9,10 Moreover, only one previous study has directly
players at the elite European club level during the same pe-
riod using the same study design,11 concluding that Swedish
male players had 20%-­40% higher injury incidence compared
to their female counterparts even though the rate of moder-
ate and severe injuries was similar. In contrast, there were
no sex differences in the overall injury incidence in National
Collegiate Athletic Association (NCAA) soccer, but the pro-
portion of severe injuries was higher in women than in men.12
Studies investigating specific injuries have reported that
hamstring strains13 and groin injuries14 are more common in
male players, whereas ACL injuries10 and concussions15 are
more frequent in female players.

Scand J Med Sci Sports. 2018;28:237–245. wileyonlinelibrary.com/journal/sms © 2017 John Wiley & Sons A/S.     237 |
Published by John Wiley & Sons Ltd
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238       LARRUSKAIN et al.
However, no study has compared the epidemiology of in-
juries in male and female football players from the same club
and with medical staffs following the same procedures for di-
agnosing, treating, and recording injuries. This is important
as there are discrepancies between medical staffs at different
clubs in their injury diagnosis, return to play, and registration
procedures, which might be a major source of bias in the com-
parison.16 Unraveling sex differences in injury epidemiology
would be valuable to tailor prevention programs, return to play
strategies, and generate hypotheses on plausible risk factors.
Thus, the aim of this study was to compare the incidence, dis-
tribution, and severity of injuries between elite male and fe-
male football players from the same club over several seasons.
2  |  M AT E R IA L S A N D ME T HODS
2.1  |  Participants and study period
Athletic Club’s elite male and female teams, both playing in
the Spanish first division, were prospectively followed for five
seasons (from July 2010 to June 2015). The female team fin-
ished all five seasons in the top 3 of the league and reached the
Spanish cup finals in two occasions. The male team reached the
Spanish Cup finals twice and UEFA Europa League finals once
and participated in the UEFA Champions League in the last
season. The study was approved by the Ethics Committee of the
University of the Basque Country (CEISH/340/2015).
2.2  |  Injury definitions and
recording procedures
The club’s medical staff, which remained the same for all
five seasons, diagnosed, treated, and recorded all time-­loss
injuries, following the consensus on definitions and data col-
lection procedures outlined by the International Federation
of Association Football (FIFA).17 Specifically, the male team
was supported by two team doctors, four physiotherapists,
and one pitch rehabilitator who is responsible for introducing
injured players to the drills and skills that will be required
when they return to full participation, whereas there were one
team doctor, one physiotherapist, one masseur, and one pitch
rehabilitator for the female team. Both medical staffs fol-
lowed common injury diagnosis, treatment, and registration
procedures, and they were present at every training session
and match. The male and female teams trained at the same fa-
cilities, and medical staffs shared the same working environ-
ment, regularly interacting to discuss injury-­related matters.
2.2.1  |  Injury definitions
Injuries were recorded in the club’s online database when a
player was unable to participate in a future training session
or match due to a physical complaint resulting from football
training or match play and was considered injured until the
medical staff cleared the player for full participation in train-
ing and match play. Injuries during national team duties were
included. Illnesses were excluded.17
2.2.2  |  Injury location and type
Injury location was recorded as follows: head/neck, upper
limbs, trunk, and lower limbs (hip/groin, thigh, knee, lower
leg, ankle, foot/toe); and injury type as follows: muscle, joint/
ligament, fracture/bone stress, tendon, contusion, laceration/
skin, and concussion.17 The specific injury diagnosis was
also recorded.
2.2.3  |  Injury mechanism and circumstance
Injuries with an acute, identifiable onset were defined as
traumatic injuries, while those with a gradual onset as over-
use injuries. Contact and non-­contact injuries were recorded
depending on whether injuries occurred due to contact with
another player or object, or not.17
2.2.4  |  Recurrent injuries
Injuries at the same location and of the same type as an index
injury were classified as early (0-­2 months after a player’s
return to full participation), late (2-­12 months), or delayed
(>12 months) recurrences.17
2.2.5  |  Injury severity
According to the number of days lost, injury severity was
recorded as minimal (1-­3 days), mild (4-­7 days), moderate
(8-­28 days), and severe (>28 days).17
2.3  |  Individual training and match
exposure time
Individual player exposure time in training and matches
(friendly and competitive), including national team exposure,
was recorded daily in minutes.
2.4  |  Data analysis
Injury incidences are presented as the number of inju-
ries/1000 player hours with 95% confidence intervals (CI)
and were compared calculating rate ratios (RR=injury in-
cidence of male players divided by the injury incidence of
female players) with 95% CI and tested using z-­statistics.18
Proportions were compared using the χ2 test with Yates’ con-
tinuity correction. Due to a non-­normal distribution, differ-
ences in days lost were compared using the Mann-­Whitney
U test. Team differences in player characteristics, exposure
time, and the percentage of player match availability were
LARRUSKAIN et al.   
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   239

compared using Student’s t test. Each season was divided differences in the proportion of traumatic and overuse injuries
into three periods: preseason (July and August), competitive (P=.47), or in the percentage of recurrent injuries (P≥.07).
phase I (from September to January), and competitive phase Total injury incidence was significantly higher in men dur-
II (from February to June). Sample size calculations showed ing the first and second competitive phases (Figure 1). The
that with 80% power and a two-­sided significance of 0.05, mean percentage of player match availability per season was
to detect significant differences between overall injury inci- similar for men and women (88±4% vs 88±8%, respectively,
dences of 7.7 injuries/1000 h in men and 5.5 injuries/1000 P=.94).
h in women,11 21 382 h of exposure per team would be re-
quired.18 The significance level was set at P<.05, and statis-
3.2  |  Injury location and type
tical analyses were performed using Microsoft Excel 2011
(Microsoft, Redmond, WA, USA) and GraphPad Prism The incidence of muscle and joint/ligament injuries was sim-
v.6.0c (GraphPad Software, La Jolla, CA, USA). ilar between men and women, but contusions were five times
more frequent in men (Table 3). Regarding muscle injuries,
men had almost a two times higher incidence of hamstring
3  |   R E S U LTS strains, while women had a two times higher incidence of
quadriceps strains, with these being the most frequent in-
Player and team characteristics are presented in Table 1. juries for each sex, respectively. Moreover, men had an 11
Total, training, and match exposure hours per player-­season times higher incidence of pubalgia cases; and there were
were 17%-­20% higher for men compared to women (P<.05). statistical trends for hip/groin injuries to be 1.58 times more
Furthermore, the male team had 35% more training sessions frequent in men, and for ACL ruptures to be almost five times
(P<.01) and 30% more matches (P=.02) per week, but the more common in women. Even though there were no sex dif-
match hours/total hours of exposure ratio was similar (P=.94). ferences in the incidence of ankle ligament sprains, the inci-
dence of ankle injuries affecting the syndesmosis was higher
for women (men [n=2] 0.05 vs women [n=7] 0.28/1000 h,
3.1  |  Injury incidence
RR=0.19 [95% CI 0.04-­0.90], P=.04). No concussions were
Total, training, and match injury incidence were 30%-­40% recorded in men or in women.
higher in men (P≤.04, Table 2). The proportion of contact
injuries was higher for men (P=.03), but there were no sex
3.3  |  Injury severity
T A B L E   1   Player and team characteristics and exposure time Women had a 21% larger number of total days lost (Table 4),
and almost a two times higher total injury burden (men: 116
Men Women
days lost/1000 h vs women: 216 days lost/1000 h, P<.01).
Total nº of players 50 35 In addition, while the incidence of minimal and mild inju-
Player seasons 127 99 ries was significantly higher in men, women suffered a higher
Age (years) 25±4 25±5 proportion of severe injuries (Table 2) and had an almost five
Height (cm) 182±6* 167±6 times higher incidence of severe joint/ligament injuries (men
Body mass (kg) 76±6* 59±7 [n=7] 0.2 vs women [n=21] 0.8/1000 h, RR=0.22 [95% CI
Team size 25±3* 20±1 0.09-­0.51], P<.01). Specifically, severe injuries affecting the
ligaments of the knee and ankle were more frequent in women
Exposure
(for both injuries: men [n=2] 0.05 vs women [n=7] 0.28/1000
Total h 38 878 25 394
h, RR=0.19 [95% CI 0.04-­0.90], P=.04). Among severe knee
Training h 33 487 21 850
ligament injuries, there were two ACL ruptures in men, and
Match h 5391 3544 six ACL ruptures and one medial collateral ligament sprain in
Total h/player/season 306±80* 257±82 women. Regarding severe ankle ligament injuries, men sus-
Training h/player/season 264±70* 221±71 tained two lateral sprains, and women suffered two medial
Match h/player/season 42±25* 36±16 sprains, two syndesmosis injuries, two sprains affecting both
Training sessions/week 5.3±0.4* 3.9±0.2 the lateral ligament and the syndesmosis and one sprain af-
Matches/week 1.3±0.2* 1.0±0.1 fecting both the medial ligament and the syndesmosis. ACL
Match exposure ratio #
0.136±0.067 0.137±0.043
ruptures were responsible for more than 40% of all absence in
women (Table 4), and joint/ligament injuries caused a higher
h: hours.
percentage of all absence in women in comparison with men.
*P<.05.
#
Match hours/total hours of exposure. Conversely, lay-­off times were more distributed across injury
Values are mean±SD. types in men, with hamstring strains being the predominant
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240       LARRUSKAIN et al.

T A B L E   2   Injury incidence in elite male and female football players

Men Women
Rate ratio
Injuries Number (%) Incidence (95% CI) Number (%) Incidence (95% CI) (95% CI) P valuea
Total 323 8.31 (7.45-­9.27) 160 6.30 (5.40-­7.36) 1.32 (1.09-­1.59) <.01
Training 160 (50) 4.78 (4.09-­5.58) 75 (47) 3.43 (2.74-­4.30) 1.39 (1.06-­1.83) .02
Match 161 (50) 29.86 (25.59-­34.85) 80 (50) 22.57 (18.13-­28.10) 1.32 (1.01-­1.73) .04
Mechanism
Traumatic 156 (48) 4.01 (3.43-­4.69) 81 (51) 3.19 (2.57-­3.97) 1.26 (0.96-­1.65) .09
Overuse 163 (50) 4.19 (3.60-­4.89) 72 (45) 2.84 (2.25-­3.57) 1.48 (1.12-­1.95) .01
Circumstance
Contact 92 (28)# 2.37 (1.93-­2.90) 30 (19) 1.18 (0.83-­1.69) 2.00 (1.33-­3.02) <.01
#
Non-­contact 226 (70) 5.81 (5.10-­6.62) 125 (78) 4.92 (4.13-­5.87) 1.18 (0.95-­1.47) .14
Recurrence
No 224 (69) 5.76 (5.05-­6.57) 124 (78) 4.88 (4.09-­5.82) 1.18 (0.95-­1.47) .14
Yes 99 (31) 2.55 (2.09-­3.10) 36 (23) 1.42 (1.02-­1.97) 1.80 (1.23-­2.63) <.01
Early 40 (12) 1.03 (0.75-­1.40) 11 (7) 0.43 (0.24-­0.78) 2.38 (1.22-­4.63) .01
Late 41 (13) 1.05 (0.78-­1.43) 13 (8) 0.51 (0.30-­0.88) 2.06 (1.10-­3.84) .02
Delayed 18 (6) 0.46 (0.29-­0.73) 12 (8) 0.47 (0.27-­0.83) 0.98 (0.47-­2.03) .96
Severity
Minimal 100 (31)# 2.57 (2.11-­3.13) 25 (16) 0.98 (0.67-­1.46) 2.61 (1.69-­4.05) <.01
Mild 95 (29) 2.44 (2.00-­2.99) 35 (22) 1.38 (0.99-­1.92) 1.77 (1.20-­2.61) <.01
*
Moderate 91 (28) 2.34 (1.91-­2.87) 64 (40) 2.52 (1.97-­3.22) 0.93 (0.67-­1.28) .65
Severe 37 (11) 0.95 (0.69-­1.31) 36 (23)* 1.42 (1.02-­1.97) 0.67 (0.42-­1.06) .09
CI: confidence interval.
a
P value for the comparison of injury incidence between men and women.
#
Higher injury proportion in men vs women (P<.05).
*Higher injury proportion in women vs men (P<.05).
Missing data, men: training/match=2, mechanism=4, circumstance=5; women: training/match=5, mechanism=7, circumstance=5.

source of absence and muscle, tendon and contusion injuries

accounting for a higher proportion of days lost compared to
women. Finally, the median absence caused by muscle and
joint/ligament injuries was larger in women.

F I G U R E   1   Distribution of total injury incidence across the
season in elite male and female football players. PS: preseason, CP:
competitive phase. Higher injury incidence in male players compared
to female players during CP I (* RR=1.35, 95% CI 1.02-­1.80, P=.04)
and CP II (# RR=1.33, 95% CI 1.00-­1.78, P=.05)
4  |  DISCUSSION
4.1  |  30%-­40% higher injury incidence in
men
The higher overall injury incidence in men is in agreement
with the only previous study prospectively comparing injury
incidence between men and women at the elite European club
level in football, where Hagglund et al.11 reported a 20%-­40%
higher injury incidence in men, but only in the incidence of
minimal and mild injuries. A higher injury incidence was
also observed in the United States Major League Soccer19
in comparison with the Women’s United Soccer Association
league.8 Junge & Dvorak20 investigated sex differences in
LARRUSKAIN et al.   
   241
|
T A B L E   3   Injury incidence according to location and type in elite male and female football players

Men Women

Incidence Incidence Rate ratio

Injuries Number (%) (95% CI) Number (%) (95% CI) (95% CI) P valuea
Location/Diagnosis
Head/neck 5 (2) 0.13 (0.05-­0.31) 3 (2) 0.12 (0.04-­0.37) 1.09 (0.26-­4.56) .91
Upper limbs 8 (2) 0.21 (0.10-­0.41) 2 (1) 0.08 (0.02-­0.31) 2.61 (0.55-­12.30) .22
Trunk 25 (8) 0.64 (0.43-­0.95) 8 (5) 0.32 (0.16-­0.63) 2.04 (0.92-­4.53) .08
  Low back pain 12 (4) 0.31 (0.18-­0.54) 6 (4) 0.24 (0.11-­0.53) 1.31 (0.49-­3.48) .59
Lower limbs 285 (88) 7.33 (6.53-­8.23) 147 (92) 5.79 (4.92-­6.80) 1.27 (1.04-­1.55) .02
Hip/groin 63 (20) 1.62 (1.27-­2.07) 26 (16) 1.02 (0.70-­1.50) 1.58 (1.00-­2.50) .05
  Adductor strain 35 (11) 0.90 (0.65-­1.25) 19 (12) 0.75 (0.48-­1.17) 1.20 (0.69-­2.10) .52
#
 Pubalgia 17 (5) 0.44 (0.27-­0.70) 1 (1) 0.04 (0.01-­0.28) 11.10 (1.48-­83.44) .02
Thigh 94 (29) 2.42 (1.98-­2.96) 48 (30) 1.89 (1.42-­2.51) 1.28 (0.90-­1.81) .17
  Hamstring strain 59 (18) 1.52 (1.18-­1.96) 20 (13) 0.79 (0.51-­1.22) 1.93 (1.16-­3.20) .01
  Quadriceps strain 17 (5) 0.44 (0.27-­0.70) 25 (16)* 0.98 (0.67-­1.46) 0.44 (0.24-­0.82) .01
Knee 37 (11) 0.95 (0.69-­1.31) 26 (16) 1.02 (0.70-­1.50) 0.93 (0.56-­1.53) .78
  Ligament injury 11 (3) 0.28 (0.16-­0.51) 14 (9)* 0.55 (0.33-­0.93) 0.51 (0.23-­1.13) .10
   ACL rupture 2 (1) 0.05 (0.01-­0.21) 6 (4)* 0.24 (0.11-­0.53) 0.22 (0.04-­1.08) .06
 Meniscus/cartilage 7 (2) 0.18 (0.09-­0.38) 8 (5) 0.32 (0.16-­0.63) 0.57 (0.21-­1.58) .28
Lower leg 34 (11) 0.87 (0.62-­1.22) 18 (11) 0.71 (0.45-­1.13) 1.23 (0.70-­2.18) .47
  Calf strain 19 (6) 0.49 (0.31-­0.77) 13 (8) 0.51 (0.30-­0.88) 0.95 (0.47-­1.93) .90
Ankle 43 (13) 1.11 (0.82-­1.49) 24 (15) 0.95 (0.63-­1.41) 1.17 (0.71-­1.93) .54
  Ligament injury 37 (11) 0.95 (0.69-­1.31) 20 (13) 0.79 (0.51-­1.22) 1.21 (0.70-­2.08) .50
   Lateral sprain 21 (7) 0.54 (0.35-­0.83) 10 (6) 0.39 (0.21-­0.73) 1.37 (0.65-­2.91) .41
Foot/toe 14 (4) 0.36 (0.21-­0.61) 5 (3) 0.20 (0.08-­0.47) 1.83 (0.66-­5.08) .25
Type
Muscle 143 (44) 3.68 (3.12-­4.33) 84 (53) 3.31 (2.67-­4.10) 1.11 (0.85-­1.46) .44
Joint/ligament 83 (26) 2.13 (1.72-­2.65) 58 (36)* 2.28 (1.77-­2.95) 0.93 (0.67-­1.31) .69
#
Contusion 59 (18) 1.52 (1.18-­1.96) 8 (5) 0.32 (0.16-­0.63) 4.82 (2.30-­10.08) <.01
Tendon 16 (5) 0.41 (0.25-­0.67) 6 (4) 0.24 (0.11-­0.53) 1.74 (0.68-­4.45) .25
Fracture/bone stress 4 (1) 0.10 (0.04-­0.27) 3 (2) 0.12 (0.04-­0.37) 0.87 (0.19-­3.89) .86
Laceration/skin 1 (0.3) 0.03 (0.004-­0.18) -­ -­ -­ -­
ACL: anterior cruciate ligament, CI: confidence interval.
a
P value for the comparison of injury incidence rates between men and women.
#
Higher injury proportion in men vs women (P<.05).
*Higher injury proportion in women vs men (P<.05).

injury epidemiology in national team tournaments, and the
injury rate was higher for men in FIFA World Cups, but not in
other tournaments. In NCAA soccer, a recent study by Roos
et al.12 showed no sex differences in injury incidence, whereas
earlier studies separately reporting data on male21 and female7
players showed a higher incidence of match injuries in men
and a higher incidence of training injuries in women.
As the incidence of muscle and joint/ligament injuries
was similar between men and women, differences in the
overall injury rate appear to be explained by the five times
higher incidence of contusions in men. The higher incidence
of contusions is also likely the reason why men had a higher
incidence of minimal and mild injuries, as 83% of contu-
sions were minimal or mild in severity (data not shown).
The higher rate of contusions in men might be due to higher
intensity and more contact situations in male football,11
­together with the fact that men appear to have a two times
higher risk of suffering an injury in tackling situations.22
In addition, the higher match congestion and larger train-
ing and match exposure per player-­season observed in male
players have been previously associated with a higher injury
incidence.23
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242       LARRUSKAIN et al.

T A B L E   4   Consequences of injuries according to location and type in elite male and female football players

Men Women

Total days Days lost per Days lost per

Injuries lost % total days lost injurya Total days lost % total days lost injurya
Location/Diagnosis
Head/neck 10 0.2 2 (1-­4) 14 0.3 3 (1-­10)
#
Upper limbs 97 2 6 (2-­48) 87 2 44 (13-­74)
#
Trunk 116 3 4 (1-­18) 65 1 7 (1-­22)
  Low back pain 74 2# 5 (1-­18) 59 1 8 (1-­22)
Lower limbs 4300 95 6 (1-­253) 5318 97* 13 (1-­836)*
Hip/groin 783 17# 8 (1-­72) 276 5 7 (2-­48)
#
  Adductor strain 407 9 9 (1-­42) 239 4 9 (2-­48)
#
 Pubalgia 314 7 8 (1-­72) 2 0.04 2
Thigh 1224 27# 7 (1-­86) 876 16 12 (2-­74)*
  Hamstring strain 864 19# 9 (1-­86) 335 6 12 (3-­74)
  Quadriceps strain 219 5 10 (2-­34) 529 10* 18 (2-­61)
Knee 1134 25 6 (1-­253) 2945 54* 20 (1-­836)*
  Ligament injury 445 10 10 (1-­190) 2478 45* 33 (2-­836)
   ACL rupture 370 8 185 (180-­190) 2364 43* 256 (225-­836)
 Meniscus/cartilage 200 4 20 (1-­118) 454 8* 42 (4-­208)
Lower leg 375 8 4 (1-­107) 453 8 18 (2-­131)*
  Calf strain 208 5 4 (1-­107) 419 8* 19 (6-­131)*
Ankle 578 13 5 (1-­237) 676 12 19 (2-­106)*
  Ligament injury 556 12# 5 (1-­237) 559 10 20 (2-­106)*
#
   Lateral sprain 175 4 6 (1-­31) 148 3 4 (2-­52)
Foot/toe 206 5# 5 (1-­57) 92 2 7 (4-­66)
Type
Muscle 1746 39# 7 (1-­107) 1557 28 12 (1-­131)*
Joint/ligament 1422 31 5 (1-­237) 3760 69* 15 (1-­836)*
#
Contusion 358 8 3 (1-­57) 38 1 4 (1-­13)
Tendon 528 12# 14 (1-­253) 39 1 5 (2-­19)
Fracture/bone stress 154 3# 25 (5-­99) 88 2 10 (4-­74)
Laceration/skin 1 0.02 1 -­ -­ -­
Total 4523 100 6 (1-­253) 5484 100 12 (1-­836)
ACL: anterior cruciate ligament, CI: confidence interval.
a
Days lost per injury are presented as median (range).
#
Higher proportion of days lost or larger absence per injury in men vs women (P<.05).
*Higher proportion of days lost or larger absence per injury in women vs men (P<.05).

4.2  |  Higher incidence of severe injuries and
longer absences in women
Despite sustaining half the amount of injuries and having a
squad with five fewer players per season compared to men,
the total number of days lost was 21% larger in women.
Moreover, the proportion of severe injuries was significantly
higher in women in agreement with data from NCAA soc-
cer,12 and injury burden, expressed as the numbers of days
lost per 1000 hours of exposure, was almost two times larger
in women. Such long lay-­off times in women are explained
by the higher incidence of severe joint/ligament injuries,
with the almost five times higher risk of ACL rupture being
the main reason. In line with these findings, previous stud-
ies have reported a 2-­3 times higher risk of sustaining ACL
injuries in female football players,10 potentially due to sex
differences in biomechanics and neuromuscular control of
the trunk, hip, and knee.9 Considering that ACL ruptures
LARRUSKAIN et al.
accounted for 43% of all absence in women, there is no ques-
tion that prevention strategies should focus on this injury, not
only to avoid lengthy player absences, but also to prevent
knee osteoarthritis.4
Severe ankle ligament injuries were also more frequent in
women. In particular, women sustained a five times higher
incidence of ankle injuries affecting the syndesmosis, which
are known to induce much longer lay-­off times compared to
other ankle ligament injuries in elite male players.24 In con-
trast, Waterman et al.25 investigated risk factors for syndes-
motic and medial ankle sprains in the United States Military
Academy and reported a higher rate of syndesmotic sprains in
male cadets playing intercollegiate soccer compared to their
female counterparts. Considering the methodological dis-
crepancies between the present study and that of Waterman
et al. (eg, population of military cadets, athlete exposure as
unit of exposure, inclusion of first-­time injuries only), and the
small number of syndesmosis injuries in both studies, more
evidence is needed to draw any decisive conclusion.
Furthermore, sex differences in recovery time from injury
are likely to exist,26 and understanding them is necessary to
adapt return to play strategies. In the present study, return
to play times from thigh muscle strains, ACL ruptures, and
calf strains was longer in women than in men, but with the
exception of calf strains, there were no statistically signifi-
cant differences. Recovery time was similar between sexes
for adductor strains and ankle lateral sprains. Previous stud-
ies in football players have not found sex differences in re-
turn to play time from ACL injury27 or hamstring strain,28
even though there is evidence suggesting that women recover
slower from concussions.29 However, this question remains
to be answered under more strict experimental conditions,
controlling for initial injury severity and standardizing return
to play protocols. A final point to consider is that the female
team had five fewer players per season. A lower number of
available players might have led to some female players play-
ing hurt or not fully recovered from minor injuries, poten-
tially increasing the risk of sustaining severe injuries.
4.3  |  Hamstring strains and pubalgia cases
were more frequent in men
In contrast to women, absence time was more distributed
across injury types in men, with muscle, tendon, and con-
tusion injuries accounting for a higher percentage of all
absence. In particular, hamstring strains were the most
common injury and the major source of absence in men.
The 93% higher rate of hamstrings strains observed in male
players is in accordance with a study by Cross et al.13 where
NCAA male soccer players were 64% more likely to sustain
a hamstring strain compared to their female counterparts.
Conversely, Hagglund et al.11 did not find significant differ-
ences. As postulated by Cross et al.,13 male players perform
  
|
   243
more high intensity runs and at higher absolute intensities,30
showing a slower recovery from them.31 Greater fatigue in
men might lead to a decreased eccentric hamstring strength32
and changes in sprinting mechanics,33 which are thought to
increase the risk of hamstring strain.34
Regarding injuries to the hip/groin area, a review on the
epidemiology of groin injuries in senior football revealed
a more than twofold higher rate in male compared to fe-
male footballers.14 In the present study, hip/groin injuries
were 1.58 times more frequent and accounted for a signifi-
cantly larger proportion of days lost in men than in women.
Specifically, the incidence of adductor strains was similar
between men and women, but the incidence of pubalgia
cases was 11 times higher in men. The predominance of
athletic pubalgia in men has been well described and at-
tributed primarily to sex differences in pelvic anatomy with
women having a lighter and wider pelvis and larger subpu-
bic angle (the angle between the inferior pubic rami) help-
ing in the transference of destabilizing forces away from the
pubic region to the lower extremities.35 Diagnosing groin
injuries is complex, and the heterogeneous taxonomy used
by clinicians and researchers is confusing. The use of the
term pubalgia was not recommended in the recent Doha
agreement meeting on terminology and definitions in groin
pain in athletes. In this regard, the term pubalgia used in the
present study included all four clinical entities for groin pain
defined in the Doha agreement meeting (adductor-­related,
iliopsoas-­related, inguinal-­related, and pubic-­related groin
pain).36
4.4  |  Higher incidence of quadriceps strains
in women
Quadriceps strain was the most common injury in this female
team, being two times more frequent compared to men. In
contrast, previous studies in Scandinavian female football
reported a four times lower incidence of quadriceps strains,
and hamstring strains were 3-­4 times more common than
quadriceps strains.11,37 The reason for this regional discrep-
ancy is unknown, but could be due to extrinsic factors, such
as playing style, climate, or training content. Kicking has
been pointed out as the primary mechanism of quadriceps
strain, and the activation of hip flexors seems important to
protect the quadriceps during the swing phase.38 In this sense,
women show a lower iliacus activation compared to men dur-
ing ball kicking,39 which might predispose women to quadri-
ceps strains and men to hip/groin injuries. The fact that men
and women play with a ball of the same weight also needs to
be considered, as women kick a relatively heavier ball. Sex
differences in training content may be another important fac-
tor (eg, the type and amount of kicking, strength, or preven-
tive training), but training content data were not collected and
it is a limitation of the study.
 |
244       LARRUSKAIN et al.
4.5  |  Methodological considerations
The present study provides a robust sex comparison of in-
jury epidemiology in elite football players by having medical
staff from the same club diagnose, treat, and record injuries,
avoiding potentially unreliable data that might come from
medical staffs at different clubs.16
However, the study also has limitations. First, the sam-
ple size of players and injuries is small, and results should
be cautiously interpreted. The analysis of only one team per
sex limits the external validity of the results. The study had
adequate power to investigate differences in the overall in-
jury incidence, but longer follow-­up periods are necessary for
specific, less frequent injuries. As an example, to detect a sig-
nificant difference between rates of 1.5 and 1.0 injuries/1000
h, with a power of 80% and a two-­sided significance of 0.05,
78 400 hours of exposure per sex would have been required,18
but the present study only had 38 878 hours in men and
25 394 hours in women.
Second, in addition to the sex differences in exposure
time, other differences might exist in training content, pre-
ventive strategies or everyday lives of the players, and these
were not accounted for. For instance, even though all female
players had professional status in the last two seasons, some
of them had jobs besides football that could alter their risk of
injury and recovery time, for example, by preventing them
from training or taking full advantage of medical treatment.
Furthermore, there were differences in the medical staff-­to-­
player ratio between teams, which might have been a major
factor in the observed differences, as a higher availability of
medical staff might increase the time spent on injury pre-
vention, treatment, and rehabilitation and the quality of such
interventions.
Third, the lack of concussions is likely an underestima-
tion as previous studies have reported that female football
teams can expect one concussion per season, being twice as
frequent in women as in men.12,15 Players might have under-­
reported or not recognized their symptoms, or the medical
staff may have failed to identify them. Diagnosing and man-
aging concussions is challenging, and as a history of con-
cussions might lead to neurocognitive deficits, adequate
procedures are needed.40
Finally, this study is useful to uncover possible sex dif-
ferences in injury risk, but can only hypothesize with regard
to their cause. Therefore, future research is required, first, to
replicate these findings in larger cohorts, and second, to ex-
plore the reasons for the differences in injury incidence and
recovery time between men and women. In addition to bio-
logical differences, male and female football differ in many
other aspects (eg, training load and content, fixture conges-
tion, staffing, dedication level), and their investigation in re-
lation to the observed injury patterns may help identify risk
factors and develop sex-­specific preventive programs. These
are necessary steps toward safer football participation in
men’s and women’s football.
4.6  | Perspective
With only one previous study directly comparing the inci-
dence of injuries in elite male and female football players at
the elite European club level,11 the present study provides
a robust sex comparison by having medical staff from the
same club diagnose, treat, and record all injuries. Injury in-
cidence was higher in men, which might be attributed to
a higher incidence of contusions. In addition, men appear
to be more predisposed to hamstring strains and hip/groin
injuries, with hamstring strains being the primary source
of absence. On the other hand, female players had longer
absences due to a higher incidence of severe knee and ankle
ligament injuries. Finally, and for the first time, a higher
incidence of quadriceps strains and ankle syndesmosis in-
juries was observed in women. In conclusion, the present
study presents findings on the differences between men and
women in injury incidence and may help clinicians tailor
preventive strategies to the specific needs of male and fe-
male football players.
ACKNOWLEDGEMENTS
JL was supported by a PhD Studentship from the Vice-­
Chancellorship for Basque of the University of the Basque
Country UPV/EHU (Euskararen arloko Errektoreordetza).
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How to cite this article: Larruskain J, Lekue JA, Diaz
N, Odriozola A, Gil SM. A comparison of injuries in
elite male and female football players: A five-­season
prospective study. Scand J Med Sci Sports.
2018;28:237–245. https://doi.org/10.1111/sms.12860