Background Top-level football referees make decisions during strenuous physical activity and often under great mental pressure. Despite their central role in a football match, little is known about referees’ health problems, particularly female referees.

Objective To investigate the prevalence and burden of health problems in female and male top-level football referees.

Design Prospective cohort study.

Setting Female and male referees from the Norwegian female and male top divisions.

Patients (or Participants) All top-level referees (n=55) were included in this study.

Interventions (or Assessment of Risk Factors) Referees reported health problems (injuries and illnesses) through text messages for 49 weeks using the Oslo Sports Trauma Research Center Questionnaire on Health Problems (OSTRC-H2).

Main Outcome Measurements Prevalence of all health problems.

Results On average, 34% (95% CI 31–36%) of referees reported at least one health problem each week, and 20% (95% CI 19–22%) reported substantial health problems. The compliance was 98.1%. The injury incidence was 3 injuries per athlete-year (95% CI 2.5 to 3.5) and 12 injuries per 1000 match hours (95% CI 7 to 19). Gradual-onset injuries were most prevalent, with an average weekly prevalence of 23%, and caused the greatest absence from training and matches (60% of total time loss). Of the 156 reported injuries, 36% were related to the lower-leg and foot. Illnesses represented a small portion of the overall burden of health problems. Female referees reported more health problems than male referees, and on-field referees reported more health problems than assistant referees.

Conclusions Top- level referees reported a high prevalence of health problems during one full season. Gradual onset injuries to the lower-leg and foot represented the highest injury burden, especially in female referees.