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Preventing injuries in professional football: thinking bigger and working together
  1. Jan Ekstrand1,2,3
  1. 1Division of Community Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
  2. 2UEFA Injury Study Lead Expert, Linköping, Sweden
  3. 3Football Research Group, Linköping University, Linköping, Sweden
  1. Correspondence to Professor Jan Ekstrand, Division of Community Medicine, Department of Medical and Health Sciences, Linköping University, Hertig Karlsgatan 13B, Linköping S-582 21, Sweden; jan.ekstrand{at}

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Avoiding injuries ensures high player availability and allows coaches to have the most complete squad possible available for training and to select their best squad for matches. In the UEFA Champions League (UCL), the unavailability of players to compete in matches due to injury averages 14% but varies between 5% and 20%.1 Lower injury rates have been linked with team success in national and international matches.2

Top players are expensive to sign (transfer fees) and they have large salaries. It has been estimated that an injured player in the starting 11 of a UCL team will cost the club around €500 000 to €600 000 a month or around between €17 000 and €20 000 a day.3 Since the average number of absence days in a UCL team with a squad of 25–28 players is around 1100 days a season, the average cost to the club due to injuries is around €20 million a season.

The UEFA Elite Club Injury Study—a unique resource

UEFA as well as world football's governing body, FIFA have observed the high risk of injury in football. They have initiated and supported research to prevent injuries. In 2001, UEFA initiated a research project to (1) increase safety by monitoring injury patterns and (2) contribute to better understanding of injuries through scientific studies and publications. This research project was the result of several years of consultation and preparation by the UEFA Medical Committee. The Elite Club Injury Study (ECIS) has been carried out over 15 seasons; with 43 top European football clubs from 16 countries having participated to date. The 32 teams that qualify for the group stage of the UEFA Champions League are all invited to participate in the study. To ensure consistency, clubs that have already participated in the study for several seasons can continue to do so. All but four of the teams that have reached the UCL semifinals since 2001/2002 have been consistently submitting data to the study, and some teams, such as Real Madrid, have sent us data every month for 15 years.

Return to play after injury

If a player gets injured, the key question is always, ‘When can he/she/I play again?’ The ECIS database can provide guidelines for return to play. We have 14 000 injuries from UCL teams in the database and the material provides a wealth of information, for example, regarding how long certain injuries take to heal.

Some injury rates in elite football have not decreased in spite of all preventive efforts

Another advantage of the ECIS long-term study is that it shows us trends. Some injuries, such as ankle sprains and medial collateral ligament injury of the knee, have decreased.4 ,5 The total injury risk, however, has remained the same during the 15 years of the study, in spite of all the preventive work carried out in the clubs.1 The most common injury, hamstring muscle injury, is even increasing year by year, as indicated in an editorial in this issue.6 One reason could be that the intensity of play has increased at the elite level,7 but if this is the case, it is all the more reason to intensify our preventive work.

Do the ECIS medical teams have the answers as to how to improve player availability?

To continually develop our knowledge and processes regarding the ECIS study, UEFA hosts an annual conference of the head medical officers of the participating clubs. These clinicians work 24/7 with the best European football teams and many of the best players in the world. When asked, ‘What are the most important factors in preventing injuries in elite level football?’, the most common answers are load on players, internal communication, leadership styles of coaches and the well-being of players.8 These answers are surprising and indicate that the health situation in a professional football club could be quite similar to any general workplace environment (sick leave being dependent on the load imposed on employees, leadership styles of managers, internal communication in the work place and the well-being of the employees). These factors are scarcely studied in sport!

We need to work together

The aetiology of injuries is multifactorial9 and the sample size of a study needs to be considered carefully. To detect moderate or strong associations between risk factors and injuries, 20–50 cases are needed; small to moderate associations require about 200 injured patients.9 To answer significant problems that are actually faced in practice, research should be guided by the opinions and experiences of those working in the field. Research studies within single clubs are interesting for that specific team but sample size provides a major limitation. Therefore, we need to work together in multi-team/multi-league studies to increase our ability to answer important, practical questions.


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  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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