Objectives This study assessed knowledge, beliefs and practices of elite female footballers regarding injury prevention.
Methods A survey was sent to players participating in the FIFA Women’s World Cup France 2019. Questions covered three injury prevention domains: (1) knowledge; (2) attitudes and beliefs; (3) prevention practices in domestic clubs. Additionally, ACL injury history was assessed.
Results Out of 552 players, 196 women responded (35.5%). More than 80% of these considered injury risk to be moderate or high. Players listed knee, ankle, thigh, head and groin as the most important injuries in women’s football. The most important risk factors identified were low muscle strength, followed by poor pitch quality, playing on artificial turf, too much training, reduced recovery and hard tackles. In these elite players, 15% did not have any permanent medical staff in their domestic clubs, yet more than 75% had received injury prevention advice and more than 80% performed injury prevention exercises in their clubs. Players identified the two most important implementation barriers as player motivation and coach attitude. Two-thirds of players used the FIFA 11+ programme in their clubs.
Conclusions This diverse group of elite players demonstrated good knowledge of risk level and injury types in women’s football. Of the risk factors emphasised by players, there was only one intrinsic risk factor (strength), but several factors out of their control (pitch quality and type, training volume and hard tackles). Still players had positive attitudes and beliefs regarding injury prevention exercises and indicated a high level of implementation, despite a lack of medical support.
- injury prevention
Data availability statement
Data collected during this survey are available upon reasonable request. Anonymous data are held by the Fédération Internationale de Football Association (FIFA) Medical Office.
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Football is one of the most popular sports for women and girls today. More than 13 million play organised football globally and there are 945 068 FIFA-registered female adult players.1 Increased participation is unfortunately also associated with increased injury rates, particularly at the elite level.2 The type and severity of injuries in women’s football is different from that in men’s football.3 For example, female footballers are three times more likely than men to suffer from ACL injury, with significant cost to the player, as well as the club and healthcare system.4 Women are also 5 years younger, on average, than their male counterparts at the time of ACL injury.5 Rehabilitation from ACL injury requires 6–12 months (and sometimes longer) and may result in early retirement from professional sports.6 7 The majority of athletes with ACL rupture will develop osteoarthritis of the affected knee within 15 years of injury.6
Injury prevention programmes have been developed to reduce the risk of football injuries, such as knee (including ACL rupture), hamstring, groin and ankle injuries.8 9 These programmes have been tested in randomised controlled trials and proven to be effective in a controlled setting.8–13 For example, the FIFA 11+ prevention programme results in a 39% decrease in football injuries, including ACL ruptures.12 14 However, several authors have reported poor compliance rates with the FIFA 11+ programme, and very little information exists on the actual adoption and implementation of these programmes in women’s football.15–17 Finch and Donaldson have highlighted the importance of effectiveness research in the real-world context of injury prevention programmes in sport.18 Even the most effective prevention programme (as demonstrated by randomised controlled trials) will not have its intended benefit if it is not adequately implemented. The RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework can be used as a practical means of evaluating prevention programmes in sports.18 One approach to improve implementation is to assess player attitudes and beliefs regarding injury prevention and potential barriers to implementation.19
This was a cross-sectional survey among elite female footballers participating in the FIFA Women’s World Cup France 2019.
The survey was sent to players from all national teams participating at the FIFA Women’s World Cup France 2019. The initial period of data collection was over 1 month during the tournament (from 7 June to 7 July 2019). The period was extended to the end of November 2019 in order to increase the response rate.
All players participating in the FIFA Women’s World Cup France 2019 were invited to participate in the survey (a total of 552 players). The World Cup presented an opportunity to assemble elite female footballers from all six confederations in one event and therefore gain an insight into injury prevention in elite female players globally. National team physicians were approached at the beginning of the tournament, first via email and then directly during the initial team meetings at the tournament, to encourage players to participate in the survey. The team physicians whose teams had not completed the survey were then reminded via email during the tournament and in person at the doping control sessions after each match. After the tournament, the online survey was kept open for another 5 months, with further email reminders, to facilitate compliance.
Players were asked to complete a single anonymous survey about injury prevention programmes at their domestic clubs. The questions focused on club practices, since players spend more time training in their clubs than as a national team. The survey was translated into all four official FIFA languages (English, German, Spanish and French) and sent via an online link and provided in person at the tournament. The survey (online supplemental appendix 1) consisted of 18 questions and took 6–10 min to complete. It was important to keep the survey as short and simple as possible to minimise the burden on players during this important tournament. Question design focused on three dimensions of the RE-AIM framework: Reach, Adoption and Implementation. Included questions assessed: (1) knowledge of injury risk and types in women’s football, (2) attitudes and beliefs towards injury prevention and potential barriers to implementation, (3) injury prevention practices in their clubs. Five-point Likert scales were used, although the addition of a ‘Don’t know’ option resulted in six response options. This was considered an optimal compromise between measurement precision and simplicity. Players were also asked about previous ACL injury.
No identifiable data were obtained during this survey and the local medical ethics committee classified this research project as exempt. Completion of the survey was considered ‘consent to participate’.
Patient and public involvement
The survey was pilot tested with two researchers, one member of the public and one female footballer prior to being sent out, and five questions were rephrased for improved clarity.
Prior to data analysis, data were coded in SPSS (IBM SPSS V.21.0, IBM, Armonk, New York, USA). Categorical variables and items from questionnaire that had a Likert scale items were presented as frequencies and percentages. χ2 test for independence was performed to determine if there were differences in percentages knowledge of risk exposure, belief of importance and practice of injury prevention for each injury type by location. P value less than 0.05 was considered statistically significant.
A total of 196 questionnaires were returned, out of a potential of 552 (35.5%). Unanswered questions (less than 0.1% in total) were eliminated from the results. The list of participating teams and response rate is presented in table 1.
Question 1 assessed the knowledge of injury risk in female footballers. Of 189 responders, 79 (41.8%) answered ‘high’, 75 (39.7%) ‘moderate’ and 18 (9.5%) ‘low’. Players’ understanding of the most common causes of injuries are represented in figure 1.
Beliefs and attitudes
Players’ beliefs (what they believe) and attitudes (what they think and feel) regarding the importance of injury prevention and the role of training time and coach motivation are demonstrated in table 2.
Perceived impact of barriers and facilitators on injury prevention programmes are illustrated in figure 2.
Injury prevention practices in their clubs
Of those surveyed, 76.5% responded that they had previously received advice regarding injury prevention programmes, and 80.3% indicated that their teams had performed injury prevention training or carried out other preventative measures to reduce injuries.
Figure 3 represents the level of medical support available at the domestic clubs of the players participating in the FIFA Women’s World Cup France 2019 and table 3 represents the type of injury prevention players are doing with their clubs, including frequency.
Figure 4 depicts player knowledge, beliefs and practices regarding specific injury regions. There was a general disparity between the three responses. Despite players knowing that the risk of injury was high, their beliefs regarding the importance of injury prevention and actual practices relating to specific injury regions were less. All these differences were statistically significant p<0.001.
ACL injury history
Thirty players (15%) reported that they had sustained a previous ACL rupture; of these players, two (7% of ACL ruptures) reported recurrent injuries. Two players (7% of ACL ruptures) had suffered bilateral ACL injuries. Injuries were distributed equally between the dominant and non-dominant legs. Of the 30 players with ACL rupture, 24 (80%) had undergone reconstructive surgery and 6 (20%) had been treated conservatively.
While the response rate was less than anticipated and varied substantially between confederations, there was no correlation between FIFA ranking (as a proxy for team level and resources) and response rate. We would therefore argue that this diverse group of surveyed female footballers at the FIFA Women’s World Cup France 2019 provides valuable and representative information regarding the knowledge, attitudes and actual injury prevention practices of some of the world’s best female footballers.
The understanding of these players regarding level and type of injury risk (knee, ankle and head injuries) reflects that of current epidemiological research. However, there seems to be a disparity between perceived injury risk factors in this group and that reported in the literature, with external risk factors (especially artificial turf and poor pitch quality) a significant concern. This suggests that, for these players, this issue has not yet been adequately examined. The majority of players feel positive towards injury prevention and are motivated to perform these exercises. According to players, the adherence to prevention programmes in their clubs is high, despite a lack of medical support in some clubs.
More than 80% of players in this group of elite female footballers indicated that their risk of injury is moderate or high. This is consistent with the literature; injury risk in male professional football is approximately 1000 times greater than in construction, manufacturing and service sectors, with increasing risk during tournaments, such as the FIFA World Cup.20–22 While the overall rate may be up to 30%–40% lower in female footballers, the rate of moderate and severe injuries seems to be higher than in males, with up to 20% more time lost due to injury.23–25 Players in our survey believed they were exposed to knee, ankle, thigh, head and groin injuries (listed in order of frequency). Research suggests that female footballers are more likely to suffer from ACL ruptures, ankle syndesmosis and quadriceps injuries than their male counterparts.25 Concussions are also more common and more severe in female footballers.26 However, they are less likely to have hamstring and groin injuries.25 27 28
It is interesting to note that female players listed only one intrinsic factor, low muscle strength, as an important risk factor for injury, followed by seven extrinsic risk factors (poor pitch quality, artificial turf, too much training, reduced recovery time, hard tackles, too little training and too many matches), all outside their control. Poor mobility (the second intrinsic risk factor) was considered the least important. However, these results should be interpreted with some caution — it is possible that education given to players regarding injury risk factors is insufficient for them to clearly appreciate the potential influence of extrinsic risk factors (such as reduced recovery, too much training and too many matches) on intrinsic risk factors (such as fatigue). Research in male football teams suggested previous injury, physical fitness and accumulated fatigue as the most important risk factors.29 30 There is a paucity of studies evaluating risk factors in high level women’s football, with a recent systematic review only able to analyse eight high-quality studies.31 Previous injury, joint laxity, higher football exposure, playing position, players’ level of balance, coordination and various psychological issues emerged as possible factors — but cumulative fatigue did not. There were conflicting findings for the effect of postural control.
It is noteworthy that, in this group of experienced, elite players, pitch quality and artificial turf emerged as the second and third most important perceived risk factors for injury. Artificial turf was a controversial issue during the FIFA Women’s World Cup Canada 2015, when the entire tournament was played on artificial turf.32 33 No significant differences in injuries were reported between artificial turf and grass in a large cohort of elite-level male and female football players.34 However, in a recent qualitative study among elite footballers, players described higher rates of perceived fatigue and higher rates of perceived injury risk on artificial turf, and a preference for natural grass.35 This discrepancy between reported injury rates and perception of players, including this group participating in the world’s most important female football tournament, suggests that further research is needed to examine this question.
Beliefs and attitudes
In our survey, players cited extrinsic risk factors for injury (those factors outside their control) as the most important for injury. Yet, more than 90% of players believed it is important to attempt to prevent injuries and 85% are either positive or very positive about prevention programmes, despite the fact that these programmes address intrinsic risk factors only. More than half disagreed with the idea that it is more important to use training time for football than injury prevention. Our findings in elite level female footballers suggest that this group is receptive to injury prevention programmes. This contrasts with the perception of medical staff in male football teams regarding the receptiveness of male footballers.29 36 Two-thirds of players believed that coach motivation is an important factor in players’ motivation for injury prevention exercises, consistent with other authors’ findings.21 29 36 37
Injury prevention practices in the clubs
Previous studies have found a relationship between the availability and education of medical staff and the implementation of injury prevention programmes.24 It is therefore interesting to note that one of the key findings in this group of elite players is that many players did not have full medical support: 33% did not have a dedicated physiotherapist in their club team, 40% did not have a team physician and almost 50% did not have a team sports scientist or strength and conditioning coach. Thirty players (15%) did not have any medical team allocated to them and six players (3%) reported no access to any medical facilities at all. Nevertheless, of those without any permanent medical staff, 66% still participated in injury prevention programmes.
Overall, more than 75% of all players surveyed had received previous advice, and more than 80% were actively participating in injury prevention programmes in their clubs. Two-thirds of players reported that they used the FIFA 11+ programme for injury prevention, and of those, more than 80% performed it at least twice per week, as recommended.38 Only one player stated that she did not do any injury prevention programme at all. Players identified player motivation and coach attitude as the two most important factors influencing injury prevention programmes in the clubs, consistent with previous research in male football clubs.39 It is worth noting that the other factors considered by players to be important (sport-specific programme, performed on the pitch, trained medical staff, coach education and good equipment) have been considered in the development of the FIFA 11+ programme, which has been promoted as a substitute for on-pitch warm-up and takes 20 min to complete.9 These findings suggest that, despite the fact that elite female football players do not all have medical support in their home clubs, they are nevertheless well-informed regarding injury prevention, well-motivated and that the implementation of injury prevention programmes in their clubs is high. However, there seems to be some lack of understanding regarding the details of injury prevention, especially regarding type of risk (intrinsic vs extrinsic) and the specific goals of each aspect of the programme. This highlights the need for better injury prevention education programmes in this group of players.
ACL injury history
The proportion of elite female footballers with a previous ACL injury is unknown. While not in a comparable population, 2.5% of high school student-athletes reported a history of ACL injury, with football listed as the cause in 60%.40 In our survey, 15% of those players who participated indicated that they had sustained a previous ACL rupture, which suggests a much higher prevalence in this population of elite female footballers, most likely due to increased exposure and age. Elite athletes with ACL rupture often have reconstructive surgery in order to return to their previous level of sport.41–43 These studies were not football-specific, but it is nevertheless interesting to note that six players (20% of those with a history of ACL rupture) were participating in this tournament with ACL-deficient knees.
There are limitations to our survey. First, the response rate was relatively low. Results therefore have to be interpreted with caution. For example, it is possible that those who responded are more concerned and informed about injury prevention than those who did not. The most likely reason for the low response rate is that we conducted the survey during the most important event on the women’s football agenda. However, this was also the best opportunity to gain access to a large and diverse cohort of elite female footballers. Second, 25% of players did not answer the question regarding the FIFA 11+ programme. This may be due to the formatting of the survey, where alternate lines were shaded to facilitate reading. Third, the survey was administered in the four official FIFA languages (English, French, German and Spanish). However, for more than 50% of the teams, the survey was not available in their home language. This may have affected the quality of answers provided, particularly for the more complicated questions. Fourth, the translated surveys were not piloted with native speakers and retranslated to ensure the questions were understood. Instead, since the survey was administered during a FIFA tournament, the standard professional FIFA translation service was used (as for all other tournament-related documentation). For future surveys of a similar nature, consideration should be given to validated translations into more languages. Fifth, our survey did not include open questions. However, open questions or qualitative interviews would provide further insights.
This diverse group of elite players demonstrated good knowledge of risk level and injury types in women’s football. In addition to low muscle strength, players listed poor pitch quality and artificial turf (two factors out of their control) as the most important causes for injury. Still, players had positive attitudes and beliefs regarding injury prevention exercises and indicated a high level of implementation, despite a lack of medical support.
A recent review of the FIFA 11+ programme highlighted the importance of the commitment of FIFA Members Associations in supporting the message of injury prevention, by educating players and coaches.38 Our survey suggests that, in this diverse group of elite female footballers at least, players have positive attitudes towards injury prevention. With the current rise in popularity of women’s football, it is important to encourage further research in injury epidemiology, and promote injury prevention, not only among players but also support staff.
What are the new findings?
We report that elite female footballers have a good knowledge of level of risk and types of injuries in women’s football, as well as positive attitudes towards injury prevention.
In this group, pitch type and quality are still considered significant injury risk factors, suggesting this issue has, from the players’ point of view, not been adequately examined yet.
This group of players report a high level of injury prevention programme implementation in their domestic clubs, despite a lack of medical support.
How may it impact on clinical practice in the future?
With the rise in popularity in women’s football, we believe it is important to promote further research and education in injury prevention programmes in this group.
Future research should aim to obtain more detailed information about injury prevention knowledge, beliefs and practices.
Female footballers seem to be aware of the fact that their injury profile may be different from their male counterparts.
Future research should focus on the sex differences in football injuries and prevention, and its clinical applications.
Data availability statement
Data collected during this survey are available upon reasonable request. Anonymous data are held by the Fédération Internationale de Football Association (FIFA) Medical Office.
Patient consent for publication
The local Ethics Review Board (Anti-Doping Lab Qatar) classified this as exempt from review.
The authors would like to acknowledge the contributions of all team physicians at the FIFA Women’s World Cup France 2019 in encouraging the players to complete the survey.
Twitter @azizfar, @JHaroey
Correction notice This article has been corrected since it published Online First. The provenance and peer review statement has been included.
Contributors All authors have contributed to this survey. CG and LG were involved in designing the protocol, administering the survey, data extraction, data analysis and co-leading of the writing. AF was involved in data extraction, analysis and co-writing of the manuscript. JH was involved in the development of the questionnaire and review of the manuscript. AW and CO were involved in the development of the questionnaire, data collection and data extraction, as well as review of the manuscript. RB was involved in development of the protocol, development of the questionnaire, data collection and review of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.