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Sport medicine research needs funding: the International football federations are leading the way
  1. Jan Ekstrand1,2,3,
  2. Jiri Dvorak4,5,
  3. Michel D'Hooghe3,4
  1. 1 Division of Community Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
  2. 2 Football Research Group, Linköping University, Linköping, Sweden
  3. 3 UEFA Medical Committee, Nyon, Switzerland
  4. 4 Medical Centre of Excellence, Schulthess Clinic, Zürich, Switzerland
  5. 5 FIFA Medical Assessment and Research Centre (F-MARC), Zürich, Switzerland
  1. Correspondence to Professor Jan Ekstrand, Solstigen 3, S-589 43, Linköping, Sweden; jan.ekstrand{at}

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This issue of the BJSM contains 10 injury surveillance articles concentrated on the world's largest and most popular sport, football. As presented by Bizzini et al, football is played by almost 300 million people—or around 4% of the world's population.1

From a medical perspective, football contains many positive motivational and social factors that may facilitate compliance and contribute to the maintenance of a physically active lifestyle.2 ,3 Recently, Krustrup et al demonstrated that football training for 2–3 h/week resulted in significant cardiovascular, metabolic and musculoskeletal adaptations, independent of gender, age or lack of experience with football.3 They conclusively showed that football provides broad-spectred health and fitness effects that are at least as pronounced as for running, and in some cases even better.3

Despite the positive effects of participating in football and other sports, negative factors, such as the risk of injury, must also be considered. Such a risk is especially pronounced at the elite level, where football is a profession. And this is not a small group; according to FIFPro, the worldwide representative organisation for all professional players, there are more more than 50 000 professional players (

Injury risk in football is substantial

The risk of injury in professional football has been estimated at about 1000 times greater than for typical industrial occupations generally regarded as high risk.4 As demonstrated by Ekstrand et al in this issue, the overall injury rate is around eight time-loss injuries per 1000 h of exposure. A time-loss injury means absence from training and matches and at the professional level, this means absence from work. An average A-team squad at the elite level includes about 25 players. If we compare the injury situation in a professional football team with a workplace with 25 employers working 40 h a week, a similar injury risk would mean around eight new injuries causing absence from work every week. It would also mean an unavailability due to injury of 12–14%. Surely, such a workplace would have been questioned, scrutinised and maybe even closed. But this is the situation in elite level football.

The ideal scenario is of course that players continue to play football, even at the professional level, but at the same time have reduced injury risk—that there is increased safety in the workplace. In theory, we know how to do this—it was pointed out by van Mechelen as the ‘sequence of prevention’.5 This four-step sequence includes injury surveillance studies as the fundamental first step in the sequence but also as the fourth step of follow-up.

Conducting injury surveillance studies: what are the benefits and practical implications for football?

Injury surveillance studies provide the following benefits at the following organisational levels of football

For international federations and national associations, surveillance studies provide:

  • An overview of injury risk/pattern for professional football players and also for players at the amateur and grassroots levels.

  • It can be considered as a duty for the governing international federations and the national associations to control the risk factors of participating in the sport. The Football Associations (FAs) and the national elite club associations have a major responsibility for risk management.

  • A tool to evaluate injury risk/trends over time and study the effects of changing external circumstances on injury risk such as rule changes, seasonal schedule changes, surfaces/turfs, number of teams.

  • A database and a tool to improve the exchange of information between national teams and clubs.

For football clubs, surveillance studies provide:

  • A first step in their risk management strategy.

  • Direct feedback of the injury situation in their club in comparison to other clubs.

  • A tool to evaluate injury risk/trends over time and study the effects of changing external circumstances on injury risk such as change of coaches, change of training programmes.

  • Medical information for seasonal evaluation and tactical performance purposes.

For players, surveillance studies provide:

  • Information about the risk of injury in their profession as footballers.

  • Information of how to avoid injuries.

Good surveillance requires funding

In a recent BJSM editorial, Dr John Orchard highlighted that good injury surveillance requires funding.6 Funding is a key factor for injury studies and the process of building up and maintaining a database and a register.6 ,7 Guaranteed funding for a period of time favours retention of good quality staff and permits quality control.7

In their survey of national arthroplasy registers, Kolling et al 7 showed that the most effective help that can be offered by government is financial support. However, in many countries, the financial support of sports medicine research is limited. Government funding of sports medicine might be an important base for research but probably needs to be complemented by other funding for optimal results.

FIFA (Fédération Internationale de Football Association) and UEFA (Union of European Football Associations) are leading the development of sports medicine research

The key to successful injury surveillance in different sports is probably funding from the international and national sports organisations. Football is leading the way by having initiated and funded research in football medicine.

As reported by Bizzini et al in this issue, FIFA started the development in 1994 by founding its Medical Assessment and Research Centre (F-MARC) in order to create and disseminate scientific knowledge on various medical topics in football, to reduce football injuries and to promote football as a health-enhancing leisure activity. Epidemiological data served as a basis to design a football injury prevention strategy.8 F-MARC developed ‘The 11’, a prevention programme for amateur and youth players, whose effectiveness has been tested in Switzerland.9 The nationwide implementation led to a decrease in injuries during matches and training. Since then, ‘The 11’ has been further developed into a complete warm-up programme—‘The 11+’. In a major study in female youth players in Norway, ‘The 11+’ resulted in the overall injury rate decreasing by a third, and the number of serious injuries by half.10

In addition to injury prevention, F-MARC has addressed a variety of other medical issues over the years, including, for example, best initial examination to reduce or even prevent sudden cardiac death11 ,12 environmental influences such as heat13 and altitude14 and the effects of fasting during Ramadan on performance.15 ,16

While FIFA has been successful in initiating research and implementing preventive programmes at the amateur and grassroot levels, UEFA has concentrated on carrying out surveillance studies at professional levels in Europe and nine different studies are reported in this issue of BJSM. The UEFA Champions League injury study, initiated in 1999 by the UEFA Medical Committee, has collected the world's largest database on elite level football injuries.

The surveillance from this study has covered more than 1.5 million training sessions and matches during 11 consecutive seasons for the best elite level teams in 10 countries in Europe. The knowledge from this ongoing survey has resulted in over 40 articles in peer-reviewed scientific journals.

In total, FIFA and UEFA have made an important impact in sports medicine research by funding and supporting sports-specific research aiming to improve our knowledge of how to keep athletes in good health. There is the highest level evidence—‘proof’—that appropriate sports injury prevention research can lead to the implementation of interventions that make sports safer.

Crippling injuries are not in the long-term interests of sports and sportspeople and parents make choices. It is in sporting organisations and their International Federations’ self-interest to seriously engage in sports injury prevention. FIFA and UEFA are two role model organisations.


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  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.