Downloaded from http://bjsm.bmj.com/ on March 7, 2018 - Published by group.bmj.

com

Original article

Epidemiology of time loss groin injuries in a men’s

professional football league: a 2-year prospective
study of 17 clubs and 606 players
Andrea B Mosler,1,2 Adam Weir,1,3 Cristiano Eirale,1 Abdulaziz Farooq,1
Kristian Thorborg,4 Rod J Whiteley,1 Per Hӧlmich,1,4 Kay M Crossley2
1
Aspetar Orthopaedic and Abstract European football, but little is known about other
Sports Medicine Hospital, Doha, Background/Aim  Groin injury epidemiology has not geographical regions.
Qatar
2
La Trobe Sport and Exercise previously been examined in an entire professional Heterogeneous classification systems have been
Medicine Research Centre, football league. We recorded and characterised time loss used to report groin injury in football. This has
La Trobe University, Victoria, groin injuries sustained in the Qatar Stars League. made it difficult to synthesise the findings of clinical
Australia Methods  Male players were observed prospectively research in this area. A systematic review of groin
3
Academic Medical Center, injury epidemiological studies highlighted the need
from July 2013 to June 2015. Time loss injuries,
Amsterdam Center of Evidence
Based Sports Medicine (ACES), individual training and match play exposure were for prospective studies to be of higher quality, and
Amsterdam, The Netherlands recorded by club doctors using standardised surveillance report detailed data on specific diagnostic catego-
4
Department of Orthopedic methods. Groin injury incidence per 1000 playing ries.3 A recent consensus meeting standardised the
Surgery, Sports Orthopedic hours was calculated, and descriptive statistics used to taxonomy and terminology used to describe hip
Research Center-Copenhagen
(SORC-C), Copenhagen determine the prevalence and characteristics of groin and groin pain, and provided a guideline to be used
University Hospital, Amager- injuries. The Doha agreement classification system was by clinicians and researchers.15 However, to date,
Hvidovre, Victoria, Copenhagen, used to categorise all groin injuries. no epidemiological studies of groin injury in foot-
Denmark Results  606 footballers from 17 clubs were included, ball have been reported using the recommended
with 206/1145 (18%) time loss groin injuries sustained classifications.
Correspondence to by 150 players, at an incidence of 1.0/1000 hours The primary aim of our study was to examine the
Dr Andrea B Mosler, Department
of Rehabilitation, Aspetar (95% CI 0.9 to 1.1). At a club level, 21% (IQR 10%– incidence, prevalence and characteristics of time
Orthopaedic and Sports 28%) of players experienced groin injuries each season loss groin injury over two consecutive seasons of
Medicine Hospital, PO Box and 6.6 (IQR 2.9–9.1) injuries were sustained per club the entire Qatar Stars League (QSL).
29222, Doha, Qatar; per season. Of the 206 injuries, 16% were minimal (1–3
​andrea.​mosler@a​ spetar.​com
days), 25% mild (4–7 days), 41% moderate (8–28 days)
and 18% severe (>28 days), with a median absence of Methods
Accepted 17 May 2017
10 days/injury (IQR 5–22 days). The median days lost Injury surveillance data were conducted prospec-
Published Online First
30 June 2017 due to groin injury per club was 85 days per season (IQR tively for the QSL during the 2013–2014 and
35–215 days). Adductor-related groin pain was the most 2014–2015 football seasons through the Aspetar
common entity (68%) followed by iliopsoas (12%) and Injury and Illness Surveillance Programme.16 The
pubic-related (9%) groin pain. QSL is the highest level of professional club football
Conclusion  Groin pain caused time loss for one in in Qatar and currently comprises 14 clubs in the
five players each season. Adductor-related groin pain first division and 18 clubs in the second division.
comprised 2/3 of all groin injuries. Improving treatment Each season, the bottom two first division clubs are
outcomes and preventing adductor-related groin pain relegated to the second division, and top two clubs
has the potential to improve player availability in from the second division are promoted to the first
professional football. division.
All first division teams were invited to participate
in the study and the consistently high-performing
second division clubs, with full-time doctors
Introduction employed by the Qatar National Sports Medicine
Groin pain is common in football1–3 and can affect Programme, were also included. The reliability
both player and team performance.4 5 However, of the injury surveillance and exposure data was
injury prevention programmes have often failed to monitored closely by the research team, with injury
demonstrate significant effects.6–8 Determining the absence time checked for accuracy against the expo-
extent of a sport injury problem through accurate sure data. Teams were excluded for that season if
injury surveillance is a key component of successful they failed to supply injury and exposure data for
injury prevention models.9 10 Better characterising more than 1 month of that season.
the burden of groin injury in football may assist in Time loss injuries and individual player partici-
designing injury prevention strategies. pation (training and match play exposure) were
Groin injury epidemiology has been described for recorded by each club doctor using standardised
a selection of teams,1 2 11 12 in subelite11 13 or junior methods described previously.1 16–18 These methods
football players.14 However, epidemiology for this are in accordance with the ‘Consensus statement on
To cite: Mosler AB, Weir A, injury has not been described in detail for an entire injury definitions and data collection procedures in
Eirale C, et al. Br J Sports Med professional league. Previous studies of groin injury studies of football (soccer) injuries’.19 Prior to the
2018;52:292–297. epidemiology have predominantly investigated season, club medical staff were provided with a

Mosler AB, et al. Br J Sports Med 2018;52:292–297. doi:10.1136/bjsports-2016-097277    1 of 7

 Downloaded from http://bjsm.bmj.com/ on March 7, 2018 - Published by group.bmj.com

Original article

Table 1  Operational definitions adapted from Werner et al1 and Ekstrand et al23

Training session Team-based or individual training that involved physical activity under the control and supervision of the club coaching staff
Match Competitive or friendly match play against another team, including league and cup official matches and friendly games
Hip/groin injury Injury located to the hip joint or surrounding soft tissues or at the junction between the anteromedial part of the thigh, including the proximal
part of the adductor muscle bellies, pubic symphysis and the lower abdomen that resulted from playing football and led to a player being unable
to fully participate in future training or match play (ie, time loss injury)
Rehabilitation A player was considered injured until club medical staff cleared the player to resume full participation in training and availability for match
selection
Recurrence Injury that occurred after a player had returned to full participation that had the same classification and on the same side as a previous injury that
occurred within the study observation period (July 2013–June 2015)
Early recurrence Recurrent injury that occurred within 2 months of a player returning to full participation
Late recurrence Recurrent injury that occurred after 2 months of a player returning to full participation
Sudden-onset injury Injury with a sudden onset that occurred during training or match play with a known cause
Gradual-onset injury Injury with an insidious onset that occurred during training or match play and with no known trauma
Dominant leg The leg preferred for a penalty kick
Injury incidence Number of groin injuries per 1000 exposure hours (=1000(∑injuries/∑exposure hours))
Injury burden Number of total days lost per 1000 player exposure hours (=1000(∑time loss days/∑ exposure hours))
Player prevalence Number of players who sustained a groin injury divided by the number of players with exposure per club per season
Severity of injury
 Minimal Time loss from training and/or match play between 1 and 3 days
 Mild Time loss from training and/or match play between 4 and 7 days
 Moderate Time loss from training and/or match play between 8 and 28 days
 Severe Time loss from training and/or match play of >28 days

study manual containing information on the injury definitions Operational terms

and process of data collection. For each injury, the club doctor Definitions used for the data collection of this study were based
completed a standardised injury card containing information on previous reports of epidemiology in football (table 1).1 13 18 23
on the injury type, recurrence, mechanism, location, diagnosis The injury cards used by the club doctors to register a groin
and severity plus activity undertaking when injured (training injury included; injury location classification based on that
or match). Injury surveillance data were requested monthly by described previously,24 as well as a more detailed description of
the research team, and the accuracy was regularly checked and the doctor’s clinical diagnosis(es). One of the authors (ABM)
clarified with the club doctor as required. The reporting of this used all these clinical information to categorise the groin injuries
study follows the ‘Strengthening the Reporting of Observational according to the classification system decided upon at the 2014
studies in Epidemiology’ (STROBE) statement.20 Doha agreement meeting.15 The categorisation for each groin
injury was independently checked by a second author (AW)
and clinical notes consulted if there was any doubt regarding
Study population
categorisation. Groin injuries were, therefore, classified into the
All participants were male professional football players who
following categories: the four clinical entities, hip-related groin
competed during the 2013–2014 and/or 2014–2015 football
pain or other, according to the definitions determined in the
seasons. Demographic information, such as age, height, weight,
Doha agreement meeting (table 2).15
leg dominance, current and history of hip/groin injury, were
obtained through the mandatory preparticipation screening
process, as previously described.21 22 Ethical approval for this Statistical analyses
study was obtained from the Shafallah Medical Genetics Centre, The proportion of all time loss injuries recorded in the cohort
Approval number: 2012–017 and the Institutional Review Board, that were diagnosed as groin injury was determined. The overall,
Anti-doping Lab Qatar, Approval number: F2013000003. training and match play incidence rates of groin injury per 1000

Table 2  Classification system of groin pain in athletes, adapted from Weir et al15
Defined clinical entities Symptoms and examination findings
Adductor-related groin pain Adductor tenderness and pain on resisted adduction testing
Iliopsoas-related groin pain Iliopsoas tenderness, more likely if pain on resisted hip flexion and/or pain on hip flexor stretching
Inguinal-related groin pain Pain located in the inguinal canal region and tenderness of the inguinal canal. No palpable inguinal hernia is present. More likely if pain
aggravated by abdominal resistance or valsalva/cough/sneeze
Pubic-related groin pain Local tenderness of the pubic symphysis and the immediately adjacent bone. No particular resistance tests to test specifically for pubic-
related groin pain
Additional categories
Hip-related groin pain Clinical suspicion that the hip joint is the source of groin pain, either through history or through clinical examination
Other Any other orthopaedic, neurological, rheumatological, urological, gastrointestinal, dermatological, oncological or surgical condition causing
pain in the groin region

2 of 7 Mosler AB, et al. Br J Sports Med 2018;52:292–297. doi:10.1136/bjsports-2016-097277

 Downloaded from http://bjsm.bmj.com/ on March 7, 2018 - Published by group.bmj.com

Original article
playing hours were calculated using the following formula: during training (63%) and were of gradual onset (68%). During
number of injuries/exposure hours×1000. Poisson 95% CIs for the study period, there were 171 (83%) first-time injuries and
the incidence rates were then calculated, and incidence rates 23 (11%) early and 12 (6%) late recurrence injuries. The overall
were compared using the χ2 test.17 25 Injury burden was also recurrence rate for groin injuries was 20%, with a recurrence
calculated using the following formula: number of total days rate of 27% for the sudden-onset injuries and 18% for the grad-
lost/player exposure hours×1000.23 Descriptive statistics were ual-onset injuries.
used to determine the prevalence of players sustaining a groin
injury per club per season and the number of groin injuries Injury categories
sustained per club per season. Descriptive statistics were also Adductor-related groin pain was the most commonly diag-
used to determine the severity and characteristics of the groin nosed entity (68%) followed by iliopsoas (12%) and pubic-re-
injuries sustained during these two football seasons. All analyses lated (9%)  groin pain (table 4). The majority of cases were
were performed using IBM SPSS V.21. diagnosed as a single entity (87%), but there were also 18 (9%)
cases where 2 entities were diagnosed and 8 (4%) cases where 3
Results entities were diagnosed. There were only three cases of multiple
Study participants entities that did not include adductor-related groin pain (table 4).
A total of 17 different clubs provided complete injury and Of the single entity cases, 17% were of minimal severity, 29%
exposure data in either season and were included in the cohort. mild, 41% moderate and 13% severe. For the multiple entity
One first division club was excluded as it failed to supply cases, there were no cases that were of minimal severity, 12%
complete data in either season, leaving 13 first division and mild, 35% moderate and 54% severe.
4 second division clubs. The included second division clubs had
Discussion
either participated in the first division in one of the seasons or
In our study, the overall incidence of time loss groin injury was
been high performing in the second division. A total of 606
1.0/1000 hours (95% CI 0.9 to 1.1) in a professional football league
male football players were included in the cohort with demo-
over two consecutive seasons. There was a five times higher injury
graphic information as follows (mean±SD): age=26±4.9
incidence rate in match play than training (p<0.0001). At the club
years, height=177±6.9 cm, weight=73±9.2 kg and body mass
level, 21% (IQR 10%–28%) of players in each club had a time loss
index=23±2 kg/m2. The percentage of football players who
groin injury each season. There were 6.6 (IQR 2.9–9.1) groin inju-
were right dominant was 80%, while 20% were left dominant.
ries sustained, resulting in a median of 85 days (IQR 35–215) lost
The cohort included 11% goalkeepers, 33% defenders, 37%
per club per season. More than half (59%) of the injuries resulted
midfielders and 20% forwards. Players were exposed to a total
in more than 1 week of time loss, and more unilateral injuries were
of 205 466 playing hours, of which 183 557 hours were spent
found on the dominant side. Adductor-related groin pain was the
training and 21 909 hours in match play. The mean exposure per
most common diagnosis (68%) and only two cases of hip-related
player per season was 234±114 hours, of which 209±105 hours
groin pain (1%) were recorded.
was training and 26±18 hours exposure in match play.
Comparison with other epidemiological studies
Incidence, prevalence and burden of groin injury Our findings of a high incidence, prevalence and burden of groin
A total of 1145 time loss injuries were recorded in the study injury in a professional football league extend previous reports
cohort over these two football seasons. Of these injuries, there among professional football team cohorts.1 2 26 The groin injury
were 206 (18%) groin injuries sustained by 150 individual incidence in the UEFA Champions League over 10 seasons was
players. Overall incidence of groin injury was 1.0/1000 hours 1.1/1000 hours (95% CI 1.0 to 1.2),1 remarkably similar to our
(95% CI 0.9 to 1.1). The incidence of groin injuries was higher findings of 1.0/1000 hours (95% CI 0.9 to 1.1). The higher inci-
during match play 3.5/1000 hours (95% CI 2.7 to 4.3) than in dence during match play 3.5/1000 hours (95% CI 2.7 to 4.3)
training 0.7/1000 hours (95% CI 0.6 to 0.8) (p<0.0001). The than training 0.7/1000 hours (95% CI 0.6 to 0.8) (p<0.001) also
median prevalence of players injured per club per season was replicates the UEFA results (3.5/1000 match hours vs 0.6/1000
21% (IQR 10–28%). There were 6.6 (IQR 2.9–9.1) time loss training hours, p<0.001). It is interesting that our findings
groin injuries sustained per season per average club roster of 30 demonstrate such similarity to that of UEFA club data, as the
players. The overall injury burden was 24.3 days/1000 hours, QSL is considered to have a lower standard of play according
with a higher burden for match play (91.6 days/1000 hours) than to international rankings of the National team and Qatari clubs.
training (16.3 days/1000 hours). The incidence rate reported in our study is higher than those
previously reported for subelite football cohorts.11 13 27
Characteristics of groin injury
Of the 206 groin injuries recorded, the severity of time loss was as How does injury rate relate to exposure and phase of the
follows (table 3): 16% were minimal, 25% mild, 41% moderate football season?
and 18% severe, with a median absence of 10 days/injury (IQR Our study is the first to report groin injury burden as a func-
5–22; figure 1). The median numbers of days lost due to groin tion of exposure, with an overall rate of 24.3 days/1000 hours
injury for each team was 85 days (IQR 35–215) per season. of player exposure. This groin injury burden is higher than the
Groin injury incidence appeared to be higher in the early 19.7 days/1000 hours previously reported for hamstring inju-
season phase (September to November) of the football year ries.23 A QSL club can expect 6.6 (IQR 2.9–9.1) time loss groin
(1.2/1000 hour and 37% of all injuries sustained; table 3). injuries per season, similar to the UEFA findings of 7.2 injuries
However, there were no statistically significant differences found per season.1 Player prevalence of 21% means that 6–7 players
between the overall or training incidence rates of the four defined per average club roster of 30 players are likely to sustain a groin
phases of the football season (p>0.08). Match incidence rate injury per season. More than half (59%) of the time loss injuries
during early season was higher than that in midseason (p=0.01). sustained were moderate or severe. The number of days lost due
More injuries occurred on the dominant side (58%), and 6% of to groin injury per club per season was high (median=85 days,
injuries were bilateral (table 3). The majority of injuries occurred IQR 35–215). Since low injury rates correlate with team success

Mosler AB, et al. Br J Sports Med 2018;52:292–297. doi:10.1136/bjsports-2016-097277 3 of 7

 Downloaded from http://bjsm.bmj.com/ on March 7, 2018 - Published by group.bmj.com

Original article

Table 3  Characteristics of groin injuries sustained

n (%) Incidence per 1000 hours 95% CI
Total injuries 206 (100) 1.0 0.9 to 1.1
Circumstance
  Training 129 (63) 0.7 0.6 to 0.8
  Match 77 (37) 3.5 2.7 to 4.3
Part of season
Preseason (July to August) total 34 (17) 0.9 0.6 to 1.2
 Training 27 (13) 0.8 0.5 to 1.1
 Match 7 (3) 2.9 1.2 to 6.0
Early season (September to November) total 76 (37) 1.2 1.0 to 1.4
 Training 43 (21) 0.8 0.6 to 1.0
 Match 33 (16) 4.6 3.2 to 6.4
Midseason (December to February) total 51 (25) 0.9 0.7 to 1.1
 Training 36 (17) 0.7 0.5 to 1.0
 Match 15 (7) 2.1 1.2 to 3.5
End of season (March to June) total 45 (22) 0.9 0.7 to 1.2
 Training 24 (12) 0.6 0.4 to 0.8
 Match 21 (10) 4.0 2.5 to 6.1
Groin injury burden Days lost/1000 hours
 Total 24.3
 Training 16.3
 Match 91.6
Severity
  Minimal 33 (16)
  Mild 52 (25)
  Moderate 84 (41)
  Severe 37 (18)
Side
  Dominant 120 (58)
  Non-dominant 74 (36)
  Bilateral 12 (6)
Onset
  Sudden 65 (32)
  Gradual 141 (68)
Injury occurrence
  First-time injury 171 (83)
  Early recurrence (<2 months) 23 (11)
  Late recurrence (>2 months) 12 (6)
Player position
  Goalkeeper 15 (8)
  Defender 67 (34)
  Midfield 77 (39)
  Forward 38 (19)
  Unclassified 9 (4)

in football,5 effective prevention and treatment of groin injury (36%), consistent with the findings of previous studies.13 This
is recommended. suggests that kicking load and/or mechanics may be a factor
There was a trend towards overall groin injury incidence being in the development of groin injury in unilateral presentations.
highest in early season, and match incidence rate was signifi- Kicking has also previously been found to be the most frequent
cantly higher in early compared with the midseason phase of injury mechanism in acute adductor strains in football players.30
the football year (p=0.01). The highest rate (33%) of adductor More detailed analyses of groin injury mechanism was beyond
muscle injuries also occurred in early season in a study of UEFA the scope of our study, but such investigations may assist in
club data.2 It is likely that these higher rates of groin injury in developing more directed injury management and prevention
early season reflect the increase in match workload that occurs strategies.
during this phase.28 29 Therefore, improved match play prepara-
tion during the preseason may be beneficial to reduce the number Classification of groin injuries according to the Doha
of groin injuries occurring during this part of the season.28 In agreement
our cohort, a predominance of unilateral injuries occurred in Adductor-related groin pain was the most common groin pain
the dominant leg (58%) compared with the non-dominant leg entity,24 both as a single entity (139/180) and in conjunction

4 of 7 Mosler AB, et al. Br J Sports Med 2018;52:292–297. doi:10.1136/bjsports-2016-097277

 Downloaded from http://bjsm.bmj.com/ on March 7, 2018 - Published by group.bmj.com

Original article

Figure 1  Severity of time loss groin injury (n=206).

with other entities (23/26). This extends the findings of prospec- femoroacetabular impingement syndrome and groin pain in
tive studies that have also found adductor injury to be the most football.31–34 Interestingly, previous investigations of bony hip
common groin injury diagnosis in European teams.1 13 The use of morphology in QSL football players have determined a high
the Doha agreement classification system to categorise the groin prevalence of cam morphology (72% of players).34 The relation-
injuries in our cohort meets the current gold standard agreed ship between the presence of cam morphology and development
upon by the expert group.15 The standardised terminology and of groin pain requires further investigation with prospective
diagnostic criteria described in this classification system may study design. However, it seems that hip joint pathology may
allow for better reproducibility of these findings, and specificity be of lower incidence in the QSL in comparison to other profes-
of groin injury prevention programmes. sional football leagues,1 despite the apparent high prevalence of
cam morphology.
Relationship between groin pain, hip-related diagnoses and
cam morphology Limitations
Hip-related groin pain was very uncommon in our study, This study was initiated prior to the publication of the Doha agree-
accounting for only 1% of groin injuries recorded. It is possible ment meeting,15 and minimal reporting standards on groin pain
that ambiguity in the Doha agreement classification system for in athletes.35 Therefore, these data represent post hoc rather than
this category resulted in an underestimation of hip-related groin a priori categorisation. However, the categorisation of groin injury
pain in our cohort. However, the low percentage of cases diag- according to the entity approach24 has been in use for several years
nosed as hip-related groin pain (1%) may also be specific to this in Qatar. The QSL club doctors have previously received education
cohort of predominantly Arab football players. Hip joint-re- and specific training to enable standardisation of clinical examina-
lated diagnoses constituted 5% of all groin injuries diagnosed tion and groin injury diagnosis prior to the data collection for this
in European professional football.1 There has been considerable study. Despite this training, there may be limitations in the accuracy
interest in the relationship between cam morphology of the hip, of the categorisation of the injury data. In cases where there was

Table 4  Categories of groin injury diagnosis (n=206)

Category Adductor Iliopsoas Inguinal Pubic Hip Other Total
Diagnoses per category, n (%) 162 (68) 29 (12) 19 (8) 22 (9) 2 (1) 6 (3) 240 (100)
Severity of injury Minimal 24 3 1 0 0 2 30
Mild 50 4 3 2 2 1 62
Moderate 60 15 5 9 0 3 92
Severe 28 7 10 11 0 0 56
Total diagnoses 162 29 19 22 2 6 240
Onset
 Sudden, n 49 8 2 4 0 6 69
 Gradual, n 113 21 17 18 2 0 171
Total diagnoses 162 29 19 22 2 6 240
No of categories per case
 Single 139 18 7 8 2 6 180
 Two Iliopsoas 4 18
Inguinal 3 1
Pubic 8 1 1
 Three Iliopsoas + Inguinal 4 8
Iliopsoas + Pubic 1
Inguinal + Pubic 3
Total cases 206

Mosler AB, et al. Br J Sports Med 2018;52:292–297. doi:10.1136/bjsports-2016-097277 5 of 7

 Downloaded from http://bjsm.bmj.com/ on March 7, 2018 - Published by group.bmj.com

Original article
doubt about the classification, the medical records were assessed Provenance and peer review  Not commissioned; externally peer reviewed.
by two members of the study team (AM and AW) to optimise accu- © Article author(s) (or their employer(s) unless otherwise stated in the text of the
racy. The data collection for this study followed methodological article) 2018. All rights reserved. No commercial use is permitted unless otherwise
recommendations for epidemiological data collection in football,18 expressly granted.
and this has been standard process in Qatar for 5 years prior to
the study commencement.17 However, missing data and unknown References
inaccuracies within the data set could potentially have affected the 1 Werner J, Hägglund M, Waldén M, et al. UEFA injury study: a prospective study of hip
and groin injuries in professional football over seven consecutive seasons. Br J Sports
results of our study. Med 2009;43:1036–40.
Finally, using a time loss injury definition is likely to under- 2 Hägglund M, Waldén M, Ekstrand J. Risk factors for lower extremity muscle injury in
estimate the true burden of groin pain in football.26 Our injury professional soccer: the UEFA Injury Study. Am J Sports Med 2013;41:327–35.
definition excluded groin pain without time loss, which is relevant 3 Waldén M, Hägglund M, Ekstrand J. The epidemiology of groin injury in senior
football: a systematic review of prospective studies. Br J Sports Med 2015;49:792–7.
considering the gradual onset of most (68%) of the groin injuries.
4 Hägglund M, Waldén M, Magnusson H, et al. Injuries affect team performance
Regular use of questionnaires about the presence and impact of negatively in professional football: an 11-year follow-up of the UEFA Champions
groin pain on the football player would provide better insight into League injury study. Br J Sports Med 2013;47:738–42.
the overall burden of this injury.26 36 37 The translation, cross-cul- 5 Eirale C, Tol JL, Farooq A, et al. Low injury rate strongly correlates with team success
tural adaptation and validation of such questionnaires for the in Qatari professional football. Br J Sports Med 2013;47:807–8.
6 Hölmich P, Larsen K, Krogsgaard K, et al. Exercise program for prevention of
commonly spoken languages and nationalities of the QSL football groin pain in football players: a cluster-randomized trial. Scand J Med Sci Sports
players would assist such future research. 2010;20:814–21.
7 Esteve E, Rathleff MS, Bagur-Calafat C, et al. Prevention of groin injuries in sports: a
systematic review with meta-analysis of randomised controlled trials. Br J Sports Med
Summary 2015;49:785–91.
Time loss groin injury is common in professional football players 8 Bahr R. Why screening tests to predict injury do not work-and probably never will…:
in Qatar, accounting for 18% of all time loss injuries. One in five a critical review. Br J Sports Med 2016;50:776–80.
9 van Mechelen W, Hlobil H, Kemper HCG, Incidence KHC. Incidence, Severity, Aetiology
players (IQR 9%–28%) will have a time loss groin injury each and Prevention of Sports Injuries. Sports Medicine 1992;14:82–99.
season. A club can expect 6.6 (IQR 2.9–9.1) groin injuries, resulting 10 Finch C. A new framework for research leading to sports injury prevention. J Sci Med
in a total of 85 days (IQR 35–215) lost per season. Over half of Sport 2006;9:3–9.
these groin injuries will result in more than 1 week of time loss, 11 Engebretsen AH, Myklebust G, Holme I, et al. Intrinsic risk factors for groin
injuries among male soccer players: a prospective cohort study. Am J Sports Med
and match play incidence is higher than training. Adductor-related
2010;38:2051–7.
groin pain is the most common diagnosis (68%). Optimising treat- 12 Arnason A, Sigurdsson SB, Gudmundsson A, et al. Risk factors for injuries in football.
ment and prevention strategies is recommended for club medical Am J Sports Med 2004;32:5S–16.
staff, particularly focussing on adductor-related groin pain. 13 Hölmich P, Thorborg K, Dehlendorff C, et al. Incidence and clinical presentation of
groin injuries in sub-elite male soccer. Br J Sports Med 2014;48:1245–50.
14 Gabbe BJ, Bailey M, Cook JL, et al. The association between hip and groin injuries in
What are the new findings? the elite junior football years and injuries sustained during elite senior competition. Br
J Sports Med 2010;44:799–802.
►► Groin injury incidence, prevalence and burden are high in a 15 Weir A, Brukner P, Delahunt E, et al. Doha agreement meeting on terminology and
men’s professional football league. definitions in groin pain in Athletes. Br J Sports Med 2015;49:768–74.
16 Bakken A, Targett S, Bere T, et al. Interseason variability of a functional movement
►► Match play injury incidence rate is higher than training and
test, the 9+ screening battery, in professional male football players. Br J Sports Med
significantly higher in early than in mid football season. 2016:bjsports-2016-096570.
►► Unilateral groin injuries were more prevalent on the 17 Eirale C, Farooq A, Smiley FA, et al. Epidemiology of football injuries in Asia: a
dominant than non-dominant side. prospective study in Qatar. J Sci Med Sport 2013;16:113–7.
18 Hägglund M, Waldén M, Bahr R, et al. Methods for epidemiological study of injuries
►► Adductor-related groin pain was the most common groin pain
to professional football players: developing the UEFA model. Br J Sports Med
entity (68%); hip-related groin pain was 1%. 2005;39:340–6.
19 Fuller CW, Ekstrand J, Junge A, et al. Consensus statement on injury definitions and
data collection procedures in studies of football (soccer) injuries. Clin J Sport Med
How might it impact on clinical practice in the near 2006;16:97–106.
future? 20 von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of
Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting
observational studies. Lancet 2007;370:1453–7.
►► The high incidence and burden of time loss groin injury found 21 Bakken A, Targett S, Bere T, et al. Health conditions detected in a comprehensive
in this study emphasises the need to better understand and periodic health evaluation of 558 professional football players. Br J Sports Med
prevent these injuries. 2016;50:1142–50.
►► A specific focus on optimising treatment outcomes and 22 Mosler AB, Crossley KM, Thorborg K, et al. Hip strength and range of motion: normal
values from a professional football league. J Sci Med Sport 2017;20:339–43.
preventing adductor-related groin pain is recommended for
23 Ekstrand J, Waldén M, Hägglund M. Hamstring injuries have increased by 4% annually
football teams. in men’s professional football, since 2001: a 13-year longitudinal analysis of the UEFA
Elite Club injury study. Br J Sports Med 2016;50:731–7.
24 Hölmich P. Long-standing groin pain in sportspeople falls into three primary patterns,
Acknowledgements  The authors would like to sincerely thank Rima Tabanji and a "clinical entity" approach: a prospective study of 207 patients. Br J Sports Med
all the staff of the National Sports Medicine Program of Aspetar Orthopaedic and 2007;41:247–52.
Sports Medicine Hospital who were integral to the data collection. 25 Frome EL, Checkoway H. Epidemiologic programs for computers and calculators. Use
Contributors  ABM designed the study, contributed to data collection, analysed of Poisson regression models in estimating incidence rates and ratios. Am J Epidemiol
and interpreted the data and drafted the article. CE, AW and AF designed the study, 1985;121:309–23.
contributed to data collection, analysed and interpreted the data and revised the 26 Thorborg K, Rathleff MS, Petersen P, et al. Prevalence and severity of hip and groin
article. KT, PH, RJW and KMC designed the study, interpreted the data and revised pain in sub-elite male football: a cross-sectional cohort study of 695 players. Scand J
the article. All authors approved the final revision of the article. Med Sci Sports 2017;27:107–14.
27 Ekstrand J, Hilding J. The incidence and differential diagnosis of acute groin injuries in
Competing interests  None declared. male soccer players. Scand J Med Sci Sports 1999;9:98–103.
Ethics approval  Shafallah Medical Genetics Center and Institutional Review 28 Gabbett TJ, Hulin BT, Blanch P, et al. High training workloads alone do not cause
Board, Anti-doping Lab Qatar. sports injuries: how you get there is the real issue. Br J Sports Med 2016;50:444–5.

6 of 7 Mosler AB, et al. Br J Sports Med 2018;52:292–297. doi:10.1136/bjsports-2016-097277

 Downloaded from http://bjsm.bmj.com/ on March 7, 2018 - Published by group.bmj.com

Original article
29 Blanch P, Gabbett TJ. Has the athlete trained enough to return to play safely? 34 Mosler AB, Crossley KM, Waarsing JH, et al. Ethnic differences in bony hip
The acute:chronic workload ratio permits clinicians to quantify a player’s risk of morphology in a cohort of 445 Professional Male Soccer Players. Am J Sports Med
subsequent injury. Br J Sports Med 2016;50:471–5. 2016;44:2967–74.
30 Serner A, Tol JL, Jomaah N, et al. Diagnosis of acute groin injuries: a prospective study 35 Delahunt E, Thorborg K, Khan KM, et al. Minimum reporting standards for clinical
of 110 Athletes. Am J Sports Med 2015;43:1857–64. research on groin pain in athletes. Br J Sports Med 2015;49:775–81.
31 Agricola R, Heijboer MP, Ginai AZ, et al. A cam deformity is gradually acquired during 36 Clarsen B, Myklebust G, Bahr R. Development and validation of a new method for
skeletal maturation in adolescent and young male soccer players: a prospective study the registration of overuse injuries in sports injury epidemiology: the Oslo Sports
with minimum 2-year follow-up. Am J Sports Med 2014;42:798–806. Trauma Research Centre (OSTRC) overuse injury questionnaire. Br J Sports Med
32 Gerhardt MB, Romero AA, Silvers HJ, et al. The prevalence of radiographic hip 2013;47:495–502.
abnormalities in elite soccer players. Am J Sports Med 2012;40:584–8. 37 Clarsen B, Bahr R, Heymans MW, et al. The prevalence and impact of overuse injuries
33 Johnson AC, Shaman MA, Ryan TG. Femoroacetabular impingement in former high- in five Norwegian sports: application of a new surveillance method. Scand J Med Sci
level youth soccer players. Am J Sports Med 2012;40:1342–6. Sports 2015;25:323–30.

Mosler AB, et al. Br J Sports Med 2018;52:292–297. doi:10.1136/bjsports-2016-097277 7 of 7

 Downloaded from http://bjsm.bmj.com/ on March 7, 2018 - Published by group.bmj.com

Epidemiology of time loss groin injuries in a

men's professional football league: a 2-year
prospective study of 17 clubs and 606
players
Andrea B Mosler, Adam Weir, Cristiano Eirale, Abdulaziz Farooq, Kristian
Thorborg, Rod J Whiteley, Per H?lmich and Kay M Crossley

Br J Sports Med2018 52: 292-297 originally published online June 30,

2017
doi: 10.1136/bjsports-2016-097277

Updated information and services can be found at:

http://bjsm.bmj.com/content/52/5/292

These include:

References This article cites 36 articles, 17 of which you can access for free at:
http://bjsm.bmj.com/content/52/5/292#ref-list-1

Email alerting Receive free email alerts when new articles cite this article. Sign up in the
service box at the top right corner of the online article.

Notes

To request permissions go to:

http://group.bmj.com/group/rights-licensing/permissions

To order reprints go to:

http://journals.bmj.com/cgi/reprintform

To subscribe to BMJ go to:

http://group.bmj.com/subscribe/