Review article

Analysis of the most frequent injuries in lower limbs in football

0000-0001-5599-8873Karen Lizeth Mendoza Lobo^{1  *}  , 0000-0003-0395-8794Maylene López Bueno²  , 0000-0002-7216-0121Magda Mesa Anoceto²  , 0000-0003-3394-5783Ardy Rafael Rodríguez García² 

¹Universidad Nacional Autónoma de Honduras. Honduras.

²Universidad de Ciencias de la Cultura Física y el Deporte "Manuel Fajardo". La Habana, Cuba.

ABSTRACT

Introduction:

The present research originated from the notable increase in injuries in football players in Honduras.

Objective:

The objective was to know the most frequent injuries and identify their location, classification and risk factors.

Material and methods:

The study used the indirect or non-interactive qualitative empirical method: consultation of official documents through the search in the database, PMC US National Library of Medicine, the keywords were used: football, most frequent injuries and risk factors, remaining 28 documents directly related to the theme.

Results:

The main results focus on the review carried out where it was verified that the most frequent lower limb injuries in football are located in: thigh-ankle, groin-hip, quadriceps-hamstrings, internal, cruciate and external ligaments. Regarding the classification, it was found that of the sports prevention group of the Spanish Society of Sports Medicine and that assumed by the Union of European Football Federations (UEFA) Champions League. Among the risk factors identified are: altered biomechanics of movement, body composition, previous injuries, flexibility deficit, insufficient development of endurance to isometric strength of the stabilizing muscles, muscle-tendon imbalance between quadriceps and hamstrings and the upper load volumes and training hours.

Conclusion:

The present study allowed assessing the most frequent injuries of the in lower limbs in football.

Key words: Injuries; Football; Location; Risk factors.

INTRODUCTION

The injuries that occur in sports practice currently represent a field of study that is highly regarded, as ^{Merayo (2011)} points out:

Athletes in their search for perfecting sports techniques and obtaining a physical condition that leads to sporting achievements can make excessive increases in training loads. This could lead to overtraining, a state that decreases performance and there is an obvious physical cause, illness or injury. Situation that persists over time despite the existence of weekly or monthly periods of recovery (p 15).

Football is a sport that is currently on the rise, more and more people practice it, enjoy it, work and invest in it, where physical condition is essential together with the development of motor skills. This sport has moved to a higher level compared to other types of ball sports. A similar idea is proposed by the International Federation of Football Associations (FIFA) (FIFA, 2016 p.19) when stating: "Football is the sport with the greatest popularity and social impact worldwide. More than 200 million people practice this sport, both in the amateur and professional fields."

For his part, ^{Garcia et al. (2015)}:

Within the sample, 72.5 % were men and 27.5% women; as well as 74.4 % were subjects up to 35 years of age and the remaining 25.6 %, older than 35 years. The sport that generated the highest number of injuries was football, 27.6 % of all accidents… (p.1).

Regarding injuries in football, ^{Junge & Dvoøák (2015)} specifically refer, "Analyzing the last absolute world championships, with an average of 1.68 injuries per game, training and game" (p.14). The high injury rate is striking, which should be considered surveillance, control and prevention.

The bibliographic search carried out on epidemiological data of sports injuries in Honduran football, so far, no official studies have been found that reveal the incidence, prevalence and severity of injuries in the professional and amateur field. The objective was focused on knowing the most frequent injuries and identifying their location, classification and risk factors as a way to guide coaches, physiotherapists, physical trainers and administrative staff linked to the Honduran National Professional Football League.

To develop the study, the indirect or non-interactive qualitative empirical method was used: consultation of official documents according to ^{Estévez et al. (2004)}. 28 scientific articles found in the PMC database were consulted using the search term Football AND more frequent injuries OR risk factors for the period 2011-2021 and master's theses, doctoral theses and digital books that are related to the search term were analyzed.

DEVELOPMENT

Classification and types of sports injuries

At present, professionals linked to sports medicine have not found a single definition for sports injury.

The Sports Prevention Group of the Spanish Society of Sports Medicine (SEMED-FEMEDE) proposes the following classification of sports injuries ^{Valle et al. (2018)} p. 10), (Table 1).

Table 1.  - Classification and types of sports injuries 

The following examples constitute an extension to what was proposed by ^{Valle et al. (2018)} in table 1:

• Rupture (tendons-ligaments) (acute injury).

• Pubalgia, plantar fasciitis, muscle tear (chronic injury).

• Cramps, stiffness, contractures (due to overuse).

• Pain due to accumulation of lactic acid (very mild), inflammation of the joint capsule of the knee (mild), stiffness (moderate), muscle contracture (serious).

• Fracture (direct injury).

• Heat stroke (indirect injury).

• Grade evaluation of a sprain (early injury).

• Evolution of dislocation to subluxation (late injury).

• Concussion to CVD (delayed injury).

A similar idea was addressed by ^{Waldén et al. (2007)} in their study with teams from the European Union of Football Associations (UEFA) Champions League, making it possible to classify injuries according to severity (p. 13). (Table 2).

Table 2.  - Classification and types of sports injuries in football assumed by the UEFA CHAMPIONS LEAGUE ^{Walden et al. (2007)}  

Type of classification to consider	Injury condition	Lesion classification	Approximate time in injury situation
According to its severity	Taking into account the days of sports leave	Minor severity Mild Moderate Severe	(4-7 days) (+ 3 days) (8-28 days) (+ than 28 days)

Incidence and severity of injuries have been found in football in Kosovo, where ^{Shalaj et al. (2016)} monitored the existence of injuries in 11 teams (143 players) from the 1st division of Kosovo. A total of 272 injuries were observed, highlighting the traumatic injuries that respond to 71 %. Injury incidence is listed per 1,000 hours of training exposure. Strains and ruptures of thigh muscles, knee ligament, meniscus and cartilage injuries represent the most frequent.

Ligament injuries most often occur during dynamic movements, such as jump-landing decelerations, maneuvers in which high-risk movement patterns are present ^{Read et al. (2016)} and are related to muscle injuries that originate during eccentric muscle contraction ^{Isern -Kebschull et al. (2020)}.

^{Kuzuhara et al. (2017)} in their study verify the incidence of injury mechanisms in 89 football players during games and training in Nagoya, Japan. They note that the overall injury rate was 2.59/1000 athlete-hours (AHs). The injury rate in the game (6.43/1000 AHs) was significantly higher in training (1.49/1000 AHs; p<.05). The most common anatomical areas of injury during games and training were the lower limbs (62.5 % and 4.02/1000 HAs versus 38.5 % and 0.57/1000 HAs, respectively). Contusions (27.6 %) were the most frequent type of injury. Most of the injuries presented were due to body contact (43.8 %, 2.81/1000 AHs), considering that injuries from other types of contact (53.8 %, 0.83/1000 AHs) were the most prevalent in training.

^{Owoeye et al. (2017)} expresses that 756 players aged 1832 years (356 males and 300 females) from 22 different teams in the Nigerian National Football Tournament were followed up on incidences of injuries. They found the overall incidence to be 113.4 injuries/1000 h (with a 95 % confidence interval of 93.7 to 136.0) equivalent to 3.7 injuries/match and the lost-time incidence to be 15.6 injuries/1000 for male players and 65.9 injuries/1000 h (with a 95 % confidence interval of 48.9 to 86.8) equivalent to 2.2 injuries/games and time-loss incidence of 7.9 injuries/1000 h for female players. The male player had a significantly higher risk of injury for an incidence rate that is understood as incidence rate ratio (IRR), IRR = 1.72 (with a 95 % confidence interval of 1.23 to 2.45). The most frequent lesions are located in the lower limbs for both genders (n = 81, 70 % and n = 31, 62 % for males and females, respectively). The lowest was contusion of the leg (n = 22, 19 %) and sprain of the knee (n = 9, 18 %) was the most common specific injury in both sexes. The majority of injuries were as a result of contact with another player (n=102, 88%males and n=48, 96%females). Male players had a significantly higher risk of injury [IRR = 1.72 (95 % CI 1.232.45)].

^{Gaspar-Junior et al. (2019)} demonstrated, that the number of injuries per athlete ranges between 0.92 and 1.43. Tendon muscle injuries, in localized joints and in the lower limbs are the most prevalent with significant differences compared to other types (p <0.05).

The proportion of the lesion was defined by ^{Lundblad et al. (2020)} defined the injury rate as the number of injuries per 1000 hours (h) of games and in the study found that 128 athletes sustained injuries to the lateral cruciate ligament (LCL) and 28 to the posterior cruciate ligament (PCL). occurring during 2,554,686 h of exposure (rate 0.05 and 0.01/1000 h, respectively). Medial rest time for LCL lesions was 15 (Q1=7, Q3=32) days, for PCL lesions 31 days (Q1=15, Q3=74). It was found that 25 % of the rest time for LCL injuries is under 7 days and 75 % is under 32 days, in particular PCL injuries 25 % of the rest time is under 15 days and 75 % are below 74 days. The LCL injury rate in matches was 11 times higher than the injury rate in training (0.21 vs. 0.02/1000 h, rate ratio [RR] 10.5, 95 % CI 7.3 to 15.1 p < 0.001) and the rate of PCL injury in matches was 20 times higher than the injury rate in training (0.056 vs 0.003/1000 h, RR 20.1, 95 %, CI 8.2 to 49.6, p < 0.001).

The study by ^{Ralston et al. (2020)} between 2004 and 2014, reports that there were 439 hip or groin injuries in football players and a general injury rate of 0.57 per 1000 injuries and when football players were exposed (Aes). Injury occurrence was similar during the regular session and after the session (IRR, 0.96; 95% CI, 0.59-1.58). Injury occurrences were higher during competition (0.69/1000 Aes) than during training (0.52/1000 Aes) (IRR, 1.33; 95 % CI, 1.08-1.63).

A total of 255 injuries of 240 players from 8 professional football teams in Germany reported that the body area affected by the injury was: knee (78.2 %), foot (46.2 %), joint dislocation (100 %), ligament rupture (82.9 %), the fracture (73.3 %). More severe specific injuries were reported, such as in the ^{Krutsch anterior cruciate ligament et al., (2020)}.

The most common injuries are located in the lower limbs (60-90%), more frequently in the knee, ankle and thigh ^{Owoeye et al. (2020)} and hamstrings ^{Junge and Dvorák (2015)} and ^{Pfirrmann groin (2016)} on the players.

Injuries risk factors

^{Read et al. (2016b)} refer to that the accumulation of high hours of training and the impact of increased volume for young athletes who are experiencing a range of growth and maturation influence the risk of injury. In this sense, the authors recommend proposals that include a reduced volume of training in the growth and maturation phases and guidelines for the provision of a greater variety of physical activities that are integrated into the components of the program.

The study by ^{Todeschini et al. (2019)} analyzed 39 professional football players, recording data such as: age, position on the field, Body Mass Index (BMI), weekly training load, duration of the race and history of thigh injuries. Knee and lumbar pain found in 15 players with pubalgia, two of them with inguinal hernia, referring an association between pubalgia and high BMI (p=0.032). Four players with pubalgia had alterations in the common aponeurosis of the rectus abdominis muscles/long abductors, while no participant in the control group had these alterations (p=0.017).

In this perspective, ^{Todeschini et al. (2019)} conclude that the evaluation of athletic pubalgia should be carried out with radiography, ultrasound and magnetic resonance imaging. A high BMI, muscle lesions, geodes and osteophytes are findings associated with pubalgia; US has low sensitivity for detecting lesions of the rectus abdominis/adductor longus muscle aponeurosis.

^{Orejel et al. (2021)} mention as determining risk factors the: altered biomechanics of the ^{Rum movement et al. (2021)}, Morphology and Anatomical Factors ^{Sandrey et al. (2018)}, ^{Rappole body composition et al. (2017)}, Altered bone density or vitamin D level ^{Rappole et al. (2017)}, ^{Nagai age et al. (2017)}, Nagai stress fractures et al. (2017), likewise, the following can be mentioned:

• Previous injuries.

• Physical overload and fatigue.

• Flexibility deficit.

• Insufficient development of the isometric strength endurance of the stabilizer muscles.

• Muscle-tendon imbalance between muscle contraction of the quadriceps, hamstring, and hamstrings.

• High volumes of loads and hours of training.

• Little eccentric training.

• Specific jobs such as intramuscular coordination.

Following the identification of injury risk factors, ^{Read et al. (2016a)} advocate the necessary development of individualized programs to reduce their risk and the most frequent injuries. It should be noted that from the field of intervention of physical activity and sport, physical exercise, warm-up, postural, strength, flexibility, balance, eccentric, proprioceptive training, for stabilizing muscles, can be implemented as primary prevention measures and workwork in arthromuscular imbalances are viable, accessible and feasible alternative to prevent injuries in football.

CONCLUSIONS

The present study allowed to assess the most frequent injuries of the lower limbs, their location and risk factors in football. The most vulnerable areas of the body to suffer injuries were ankle, knee and thigh. Among the risk factors identified, altered biomechanics of movement, body composition, previous injuries, lack of flexibility, insufficient development of endurance to isometric strength of the stabilizing muscles, muscle-tendon imbalance between quadriceps and hamstrings, stood out. the high volumes of loads per hour in the training and the control of the hours of games which must be considered to propose a design of physical exercise protocols and/or preventive training programs.

Regarding the classification, the following were found: that of the sports prevention group of the Spanish Society of Sports Medicine and that assumed by the Union of European Football Federations (UEFA) Champions League.

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Received: December 17, 2021; Accepted: September 24, 2022

^*Autor para la correspondencia: [e-mail]

Los autores declaran no tener conflictos de intereses.

Los autores han participado en la redacción del trabajo y análisis de los documentos.