Knee Surgery, Sports Traumatology, Arthroscopy (2020) 28:1325–1332

https://doi.org/10.1007/s00167-019-05470-x

HIP

Epidemiology of hip and groin injuries in Swedish male first football

league
Filip Lundgårdh1 · Kjell Svensson2 · Marie Alricsson3

Received: 7 November 2018 / Accepted: 4 March 2019 / Published online: 20 March 2019
© The Author(s) 2019

Abstract
Purpose This study aimed to investigate the incidence, pattern, and burden of hip/groin injuries in Swedish professional
male football players over five consecutive seasons.
Methods Injury history from 16 football teams in the Swedish male first football league was evaluated during five consecu-
tive seasons. The team’s medical staff recorded team exposure and time-loss injuries prospectively between 2012 and 2016.
Results In total, 467 time-loss injuries located in the hip/groin area were recorded among 1,687 professional male foot-
ball players, with an overall incidence and burden of 0.82/1,000 h and 15.6/1,000 h, respectively. There appeared to be an
increased risk of hip/groin injuries during the last two seasons (2015–2016); however, the difference was not statistically
significant (n.s). Recurrent injury rate was relatively low (14%), and overuse injuries accounted for the majority of injuries
and absence days. Muscle injuries were the main injury type, while kicking and sprinting/running were the primary causes
of injury. Goalkeepers had the lowest percentage of injuries and absence days.
Conclusion Hip/groin injuries are a substantial problem in football, but does not seem to be an increasing phenomenon in
the Swedish male first football league. Index and overuse injuries accounted for the majority of injuries and absence days.
Thus, the focus should be on preventing hip/groin injuries to lower the injury rate. These new findings should be taken into
consideration when designing and implementing preventive training interventions.
Level of evidence II.

Keywords Burden · Incidence · Injury rate · Professional · Risk factors · Soccer

Introduction consensus statements [36]. As an example, Serner et al. [27]

found 33 different diagnoses used in 72 studies, where most
The hip/groin is one of the most injury prone areas in foot- of the diagnostic criteria either were not reported or used in
ball [7]. It constitutes approximately 11–17% of all injuries excess. Increasing interest in this specific area has resulted
in professional football [37], with frequencies as high as in recent consensus concerning standardisation of taxonomy
19% [32]. and terminology [13, 35, 36].
However, the hip/groin is, difficult to diagnose and treat Epidemiological research in football is often described
due to the complexity of the region [38] and the lack of either during one season [2, 18], part of a season [3, 9],
or comprised of rather small sample sizes [22]. Extensive
research has been conducted in Europe and Scandinavia
* Marie Alricsson at club level, by focusing on injury incidence and injury
[email protected]
pattern [32]. However, there are fewer studies concentrat-
1
Department of Health Sciences, Swedish Winter Sport ing on hip/groin injuries, where the focus has been on a
Research Centre, Mid Sweden University, Östersund, selection of European teams [37, 38] or non-professionals
Sweden [20, 31]. Nonetheless, there was one recent study that used
2
Department of Molecular Medicine and Surgery, Stockholm injury surveillance to describe hip/groin injuries in a profes-
Sports Trauma Research Centre, Karolinska Institutet, sional league [23]. Despite the growing amount of hip/groin
Stockholm, Sweden
research in football, little is known about seasonal variations
3
Department of Sports Science, Linnaeus University, in professional league football. To the best of the author’s
391 82 Kalmar, Sweden

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1326 Knee Surgery, Sports Traumatology, Arthroscopy (2020) 28:1325–1332

knowledge, no previous study has investigated variations absence days (days lost due to injury), were extracted from
between seasons for an entire professional league. the Swedish National Injury Surveillance Database [30].
The aim of the present cohort study was to investigate This injury surveillance database is used prospectively by
the incidence, pattern, and burden of hip/groin injuries in medical teams in the Swedish first football league to report
Swedish professional male football players over five con- injuries and treatment of individual players. Injuries that
secutive seasons. cause time-loss are registered with an injury card, which
follows the consensus on injury definitions and data col-
lection procedures in football studies [11]. This reporting
Materials and methods system enables extraction of data for statistical purposes and
to design epidemiological studies on football injuries.
The present cohort study of Swedish professional male
football players was carried out over five consecutive sea- Definitions
sons, from 2012 to 2016. The Swedish first football league
consists of 16 teams annually. Over five seasons, there has All injuries sustained by a player during football play (train-
been a total of 80 team seasons (2,299 players, age range ing and/or match) and resulting in time-loss (a player being
16–44), with 23 different teams competing. Four of these unable to participate fully in future training or match play)
teams, equal to 400 players and 14 team seasons, have not are defined as injury and should be registered in the Swed-
collected data for the Swedish National Injury Surveillance ish National Injury Surveillance Database [30]. A recurrent
Database [30] on annual basis and are, therefore, excluded injury is defined as an injury occurring after a player returns
in the present study. One team, equal to 154 players and five to full participation from an index injury of the same type
team seasons, did not submit their written consent in time and at the same site as the first injury [11]. In accordance
for data extraction and is, consequently, excluded from the with the consensus on injury definitions and data collec-
present study. Two teams, equivalent to 58 players and two tion procedures in football studies, injury incidence is cal-
team seasons, registered data between the 2012 and 2015 culated as the number of injuries per 1000 exposure hours
season and are accordingly included in those seasons in the [11]. Injury burden is calculated as the number of days lost
present study. per 1000 h of exposure, according to Bahr et al. [5].
Ethical approval was obtained from the Regional Ethi-
cal Review Board in Umeå, Sweden (2016/491-31), and the
study was conducted in accordance with the Declaration of Statistical analysis
Helsinki for Human studies.
Collected data were analysed using Microsoft Excel 2016
Data collection ver. 15.33 (Microsoft Co. Redmond, WA, USA) and IBM
SPSS Statistics ver. 24.0 (IBM Co. Armonk, NY, USA).
A total of 59 team seasons were included, involving 16 dif- Descriptive statistics are presented as frequency, percent,
ferent teams, with seven of the teams participating during all mean, standard deviation (SD), 95% confidence interval
five seasons. Teams participated in a mean±SD of 3.7±1.5 (95% CI), median, interquartile range (IQR), and range.
seasons (range 1–5). There were 1,687 players in total, with Inferential statistics were used when analysing incidence
an average of 29 players per team (range 23–34), divided and burden between seasons. A one-way analysis of vari-
by 11% goalkeepers (n = 186), 35% defenders (n = 585), ance (ANOVA) was used to compare normally distributed
34% midfielders (n = 579), and 20% forwards (n = 337). data, and the Kruskal–Wallis H test was used when data
Anthropometric data for the included football players were were not normally distributed. The significance level was
25±5 years (range 16–44), with a height of 183±6 cm (range set at 5% (p < 0.05).
166–200) and weight of 78±7 kg (range 53–96).
Staff members from all 16 medical teams were initially
contacted, between December 2016 and February 2017, and Results
provided with oral and written information about the study.
All teams consented in writing to participate in the pre- In total, 467 time-loss injuries located to the hip/groin were
sent study. Data regarding player and team characteristics recorded among 1687 professional football players. The total
(player position, age, height, weight and squad size) were exposure (training and matches) for 59 team seasons was
collected through the website Elitefootball.com [10], which 566,145 h, with a mean ± SD of 9596 ± 2362 h per sea-
provides such data on the official website of the Swedish first son. As a result, injury incidence was 0.82/1000 h (95% CI
football league [24]. All other data, such as total team expo- 0.71–1.01). Results did not reveal any significant differences
sure (training and playing time), injuries (time-loss), and between seasons F(4, 54) = 1.42, n.s. The median prevalence

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Knee Surgery, Sports Traumatology, Arthroscopy (2020) 28:1325–1332 1327

of time-loss injuries was 7.0 (IQR 4.5–11.0) per season per Table 2  Characteristics of hip/groin injuries
club, with an average of 29 players. Number Percentage Incidence/burden
The overall injury burden was 15.6/1000 h (95% CI
11.9–20.6). Results showed that there was no statistically Injuries
significant difference in injury burden between seasons, Overuse 258 55 0.46a
X2(4) = 5.401, n.s., with a mean rank burden of 30.58 for the Traumatic 209 45 0.37a
2012 season, 37.30 for the 2013 season, 21.50 for the 2014 Absence days
season, 33.38 for the 2015 season, and 28.17 for the 2016 Overuse 6022 69 10.6b
season. The median day lost due to injury was 97 days (IQR Acute/trauma 2719 31 4.8b
50–209) per season per club. Descriptive data regarding fre- Injuries
quency, incidence, and burden are summarised in Table 1. Index injuries 402 86 0.71a
Characteristics of hip/groin injuries are presented in Recurrent injuries 65 14 0.11a
Table 2, and types of injuries in hip/groin are presented in Absence days
Table 3. Index injuries 7239 83 12.8b
Overuse mechanism was found to be the most frequent Recurrent injuries 1500 17 2.6b
determining factor, with 28% injuries, followed by unknown Percentage refers to the total number of injuries and absence days in
mechanism (18%), kicking (15%), sprinting/running (13%), this table
and stretch situations (9%) (Fig. 1). However, when looking a
Incidence and bburden are presented as injuries and absence
at absence days from football play, the unknown mechanism days/1000 h of exposure respectively
was the most commonly observed (31%), followed by over-
use (27%), sprinting/running (12%), kicking (11%), change
of direction (7%), and stretch situations (7%) (Fig. 2). Discussion
Player position The main finding in the present cohort study was that hip/
groin injuries do not seem to be an increasing phenom-
Defenders sustained most hip/groin injuries, which also enon in the Swedish male first football league. In addi-
were the most severe ones, followed by midfielders, for- tion, index and overuse injuries accounted for the majority
wards, and goalkeepers (Table 4). However, when adjusting of injuries and absence days. Therefore, more attention
for the number of players in their respective positions, both should be paid to preventing hip/groin injuries to lower
defenders and midfielders sustained 29% each of the total the injury rate.
injuries, but defenders alone sustained most of the absence
days (33%) (Table 4).

Table 1  Frequency of hip/groin injuries in Swedish professional football

Season 2012 2013 2014 2015 2016 Total

No. of injuries 94 76 78 118 101 467

No. of training injuries (%) 66 (70%) 53 (70%) 53 (68%) 79 (67%) 67 (66%) 318 (68%)
No. of match injuries (%) 28 (30%) 23 (30%) 25 (32%) 39 (33%) 34 (34%) 149 (32%)
No. of injuries per c­ luba 6.5 (3.0–11.3) 7.0 (4.5–10.5) 5.0 (2.0–9.3) 7.0 (6.0–10.0) 8.0 (5.0–11.0) 7.0 (4.5–11.0)
No. of absence days 1889 2147 1146 2427 1234 8843
No. of training absence days 1412 (75%) 1657 (77%) 914 (80%) 1977 (81%) 725 (59%) 6685 (76%)
(%)
No. of match absence days (%) 463 (25%) 490 (23%) 232 (20%) 360 (15%) 509 (41%) 2054 (23%)
No. of absence days per ­cluba 155 (56–225) 209 (146–243) 59 (26–107) 109 (59–172) 68 (48–133) 97 (50–209)
No. of exposure hours 127 571 110 776 118 759 112 741 96 299 566 145
Incidenceb 0.74 (0.41–1.05) 0.69 (0.39–1.02) 0.66 (0.33–1.07) 1.05 (0.65–1.51) 1.05 (0.71–1.39) 0.82 (0.71–1.01)
Injury ­burdenc 14.8 (8.0–20.5) 19.4 (10.7–29.6) 9.6 (2.4–19.1) 21.5 (6.3–39.0) 12.8 (5.8–21.7) 15.6 (11.9–20.6)
a
Data presented as median (IQR)
b
Incidence presented as injuries/1000 h of exposure (95% CI)
c
Injury burden presented as absence days/1000 h of exposure (95% CI)

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Table 3  Injury type of hip/groin Injuries n (%) Incidence Absence days n (%) Burden
injuries
Muscle rupture/tear/strain/cramps 278 (60) 0.5 3292 (39) 6.0
Unspecific overuse symptoms 113 (24) 0.2 3123 (37) 5.7
Tendon injury/rupture/tendinosis/bursitis 28 (6) 0.05 419 (5) 0.7
Other injuries 23 (5) 0.04 1407 (16) 2.5
Contusion 17 (4) 0.03 117 (1) 0.2
Haematoma 4 (1) 0.007 79 (1) 0.1
Synovitis/joint swelling 4 (1) 0.007 75 (1) 0.1

Percentage refers to the total number of injuries and absence days in this table
Incidence are presented as injuries/1000 h of exposure. Burden are presented as absence days/1000 h of
exposure

Fig. 1  Total number of injuries

by each injury mechanism dur-
ing the 2012–2016 seasons

Fig. 2  Total number of absence

days by each injury mechanism
during the 2012–2016 seasons

Hip and groin injury epidemiology reported rate (1.0/1000 h) in the UEFA Elite Club Injury
Study [37]. The incidence was, however, greater than those
The total incidence of hip/groin injuries was 0.82/1000 h, reported from Scandinavian sub-elite and amateur level [2,
which is lower than the previous research from professional 9, 20], which might suggest that hip/groin injuries tend to
football in Sweden (range 1.0–1.3/1000 h) [17, 18] and the increase with higher level of play. One explanation for this

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Table 4  Injuries and absence days by position refers to the risk of absence from football play, which could
Injuries Percentage a
Absence days Percentage a vary depending on the severity of injuries. Like incidence,
burden can also mean natural variations between seasons
Goalkeeper 27 6 390 5 that hypothetically can depend on factors such as coaching
Defender 165 38 3387 41 philosophy, seasonal workload, and injury management.
Midfielder 160 36 2723 33 Burden has not been a standard measure in earlier stud-
Forward 88 20 1682 21 ies; therefore, there is limited research for comparisons.
a
Percentage refers to the number of injuries and absence days per Thus, the overall injury burden of hip/groin injuries was
position divided by the total number of injuries and absence days in 15.6/1000 h and is lower than the 24.3/1000 h found in
this table Qatar’s first league [23]. This difference could partly depend
on the number of seasons investigated, where Mosler et al.
[23] only studied two seasons compared to five in the present
trend could be the heavier training and match load for the one. However, new data from Werner et al. [37] suggest
most successful teams in Europe, which play both domestic that the injury burden in the Swedish first football league
and international games such as in the UEFA Champions is almost the same as in the UEFA Elite Club Injury Study,
League and Europa League. Players from the best teams also where the rate is 16.1/1000 h.
tend to play for their national teams, which further increases Recently published time-trend analysis of ankle and ham-
their seasonal workload. Other factors that hypothetically string injuries in the UEFA Champions League makes it
might influence injury risk could be differences in tactics, possible to compare injury risk with the hip/groin findings
climate, field surface, playing style, and match intensity. In in the present study. The overall incidence and burden are
addition, Waldén et al. [34] concluded that regional differ- slightly higher for both ankle (1.0/1000 h and 16.3/1000 h)
ences in injury epidemiology exist and should be considered [33] and hamstring injuries (1.2/1000 h and 19.7/1000 h) [8]
when comparing football studies. However, there was a trend compared to the results of hip/groin injuries (0.8/1000 h and
towards an increasing incidence over five consecutive sea- 15.6/1000 h) in the present study. However, when comparing
sons in the present study, with the injury rate being approxi- UEFA Champions League incidence between the different
mately 43% higher during the last two seasons (2015–2016) injury locations, injury rate is surprisingly consistent (hip/
than the initial three (2012–2014). However, this comparison groin 1.0/1000 h, ankle 1.0/1000 h, hamstrings 1.2/1000 h)
did not reach statistical significance. This is an interesting [8, 33, 37], establishing hip/groin injuries as a substantial
finding, since it differs from the reported data in the UEFA problem in professional football.
Elite Club Injury Study, where the incidence was found to be A considerably large amount of hip/groin injuries appear
slightly decreasing over a 15-year period of time [37]. One every season in Swedish professional football, and the true
potential reason for this sudden increase in incidence during magnitude might be underestimated, because the current
the 2015 season could partly be explained by the publication methodology only covers time-loss injuries [14]. Since foot-
of the consensus statement on hip/groin injury definitions ball injuries seem to be the most common cause for players
and terminology the same year [35]. With a better under- being unavailable for football activities during the competi-
standing about diagnostic criteria, medical teams might have tive season [25] and can affect team performance negatively
captured more injuries leading to an increase in incidence. [19], teams are recommended to implement evidence-based
Nevertheless, when comparing seasonal incidence in the preventive training exercises. One potential exercise that
present study with the previous studies from professional teams could consider is the Copenhagen hip adduction exer-
male football in Sweden, the injury rate lies around 1.0 cise due to its eccentric strengthening of the adductors [15,
injury per 1000 exposure hours (range 0.7–1.3, median 1.0) 21]. Teams should also be aware of the fluctuations in both
[17, 18]. This suggests that the injury incidence is not an incidence and burden, since these measures affect player
increasing phenomenon in Swedish professional male foot- availability and thereby team success [19].
ball over a longer period of time, and that seasonal changes
happen more often due to natural variations. This is some- Injury characteristics
what supported by Bjørneboe et al. [6] who found acute
hip/groin match injury incidence to be fluctuating over six The present study displayed a relatively low recurrence
consecutive seasons in the Norwegian professional league, rate for hip/groin injuries (14%) compared to the previous
with approximately the same range (0.6–1.4) as earlier stud- findings [1, 16, 23, 38], where injury rates have been found
ies, including the present one, have reported [17, 18]. to vary between 15 to 50%. The higher rates were primar-
The seasonal burden was found to be more inconsistent ily found in studies comprising rather small sample sizes
(range 9.6–21.5 absence days) than the injury rate, and the or few seasons, which could partly explain the differences.
present study could not present any increasing trend. Burden Nonetheless, recently published data from the UEFA Elite

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Club Injury Study suggest that the recurrence rate is even injuries in professional football, it could be used in the future
lower (11%) [37]. This may be related to greater invest- to compare burden in football studies.
ments in medical teams in Europe’s top division teams that A clear limitation of the present study is the use of a
hypothetically would result in better care of players than time-loss injury definition that may underestimate the risk
at lower levels. of overuse injuries [4, 14], which represents at least 50% of
One can argue that recurrent injuries are a medical team hip/groin injuries [20, 23, 37, 38]. Therefore, a combined
issue, where players get a suboptimal rehabilitation and method that captures “all physical complaints” is recom-
are forced into participating in football activities earlier mended, but, since the present study is epidemiological,
than required. it cannot demonstrate the cause-and-relationship effect.
The majority of hip/groin injuries in the present study In addition, the present study does not present the overall
are, however, a result of overuse and primarily affected injury rate, which would have been beneficial to conclude
muscles, as found in the other studies [20, 23, 38]. Over- the extent of hip/groin injuries in the Swedish first football
use injuries are strongly related to drastic changes (spikes) league. In addition, it would have been a strength if the pre-
in weekly workload and have lately been considered as a sent study reported hip and groin injuries separately, as these
training load error [12], which could suggest that the sea- could be defined as two different anatomical areas. However,
sonal workload is the main problem concerning hip/groin when combined, it makes it easier to compare with earlier
injuries in the Swedish first football league and needs to studies, because this definition is still a consensus [11]. Fur-
be managed better. thermore, the present study does not report specific diagno-
The findings in the present study of a high prevalence sis or clinical entities, which would have been preferable,
of unknown mechanism and overuse mechanism could, to since a few studies have addressed this topic [32]. Finally,
some degree, be explained by the previous lack of consensus the results in the present study could potentially have been
concerning terminology and taxonomy [35, 36]. Implemen- affected by missing data and inaccuracies in the data set.
tation of these recommendations is strongly recommended to However, injury registration is done by professional medical
ensure correct diagnosis. Another issue could be the injury teams and substantial guidelines are available, both within
registration. If an injury appears during training and the the injury surveillance database and through evidentially
medical staff are not around at the exact moment and the consensus recommendations [11].
player cannot remember how the injury happened, it could
end up as an unspecific or overuse mechanism during injury
registration.
As for the specific mechanisms, kicking was the main Conclusions
cause of injury, while sprinting/running represents most
of the absence days. These two risk factors have recently The present study suggests that hip/groin injuries are a
been associated with the main mechanisms in rectus femo- substantial problem in football, but does not seem to be
ris injuries [29], whereas kicking and change of direction an increasing phenomenon in the Swedish male first foot-
seem to be the main risk factors for adductor longus strains ball league. Index and overuse injuries accounted for the
[28]. Together with stretch situations, these four injury situ- majority of injuries and absence days. Risk factors include
ations confirm the previous research as the key mechanisms mechanisms such as kicking, sprinting/running, change of
in team sport athletes [26]. Further conclusions could not direction, and stretch situations, and being an outfield player.
be stated in the present study and should be addressed in Medical and fitness staff should focus on strategies to pre-
future studies. vent first-time injuries and overuse symptoms transforming
The main strength of the present study is that the data into injuries to decrease the hip/groin injury rate.
collections were conducted prospectively over several sea-
sons and include a substantial homogenous group of pro- Acknowledgements The authors express their sincere gratitude
to Associate Professor Magnus Forsblad for access to the Swedish
fessional football players. In addition, data were obtained National Injury Surveillance Database.
from an injury surveillance database, which is developed for
statistical purposes, and follows the international consensus Funding The authors received no financial support for the research,
agreements on injury definitions and data collection proce- authorship, and publication of this article.
dures in epidemiological studies on football injuries [11].
Another strength is the implementation of injury burden that Compliance with ethical standards
together with incidence illustrates a relationship between
the consequence (burden) and the likelihood (incidence) of Conflict of interest F. Lundgårdh, M.Sc., RPT, K. Svensson, M.Sc.,
RPT, and M. Alricsson, Ph.D, RPT declare that they have no conflict
injuries [5]. Since the present study is only the third one to of interest.
use injury burden as a measure of absence risk for hip/groin

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Knee Surgery, Sports Traumatology, Arthroscopy (2020) 28:1325–1332 1331

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credit to the original author(s) and the source, provide a link to the male and female elite football players. Scand J Med Sci
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