Time-trends and circumstances surrounding ankle
injuries in men’s professional football: an 11-year
follow-up of the UEFA Champions League
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Division of Community
Medicine, Department of
Medical and Health Sciences,
Football Research Group,
Division of Physiotherapy,
Department of Medical and
Health Sciences, Linköping
University, Linköping, Sweden
Dr Markus Waldén, Division of
Department of Medical and
Health Sciences, Linköping
University, Linköping 581 83,
Accepted 1 April 2013
To cite: Waldén M,
Hägglund M, Ekstrand J. Br
J Sports Med 2013;47:
Background Ankle injury is common in football, but
the circumstances surrounding them are not well
Aim To investigate the rates, especiall y time-trends, and
circumstances of ankle injuries in male professional
Methods 27 European clubs with 1743 players were
followed prospectively between 200 1/2002 and 2011/
2012. Time loss injuries and individual-player exposure
during training sessions and matches were recorded.
Injury rate was de ﬁned as the number of injuries/1000 h.
Results A total of 1080 ankle injuries were recorded
(13% of all injuries) with lateral ligament ankle sprain
being the most common injury subtype (51% of all
ankle injuries). The rates of ankle injury and ankle sprain
were 1/1000 h and 0.7/1000 h, respectively. The ankle
sprain rate declined slightly over time during the 11-year
study period (on average 3.1%/season) with a
statistically signiﬁcant seasonal trend (p=0.041). Foul
play according to the referee was involved in 40% of the
match-related ankle sprains. Syndesmotic sprains and
ankle impingement were uncommon causes of time loss
(3% each of all ankle injuries).
Conclusions Lateral ligament ankle sprain constituted
half of all ankle injuries in male professional football,
whereas ankle impingement syndromes were uncommon.
The ankle sprain rate decreased slightly over time, but
many ankle sprains were associated with foul play. Our
data extend the body of literature that provides football
policy makers with a foundation to review existing rules
and their enforcement.
Ankle injuries account for 10–18% of all injuries in
Sprains constitute between
51% and 81% of all ankle injuries in these studies,
and more than three-quarter of the ankle sprains
affect the lateral ligaments.
Many ankle sprains
occur as a result of player contact,
tackling and foul play involved,
and a common
football-speciﬁc injury mechanism with direct
impact on the medial aspect of the lower leg by an
opponent tackling before or at foot strike resulting
in a forced inversion of the ankle joint has been
The epidemiology of ankle sprains in football is
fairly well described, but knowledge about other
ankle injuries, such as fractures and impingement,
on the overall injury burden and player availability
is scarce. Previous studies suggest that the ankle
sprain rate is lower nowadays than during the
1980s and 1990s,
but long-term prospect-
ive studies that have investigated the development
of ankle injuries over time are lacking. We investi-
gated the rates, especially time-trends, and circum-
stances of ankle injuries in male professional
football in Europe over 11 consecutive seasons.
MATERIALS AND METHODS
The current survey is a substudy of a prospective
cohort study evaluating male professional football
in Europe in collaboration with the Union of
European Football Associations.
A total of 27
clubs from 10 countries with 1743 players (a mean
squad size of 28 players were followed over a
varying number of seasons from 2001 to 2012
(160 club-seasons and 4375 player-seasons were
included for analysis).
The studied seasons were
divided into preseason ( July and August) and com-
petitive season (September–May). The study design
adheres to the consensus statement on injury deﬁni-
tions and data collection procedures in football,
and the general methodology has been reported
Supplementary online-only ﬁles 1
and 2 show the study design and the forms used
and also the manual with practical instructions.
Inclusion criteria and deﬁnitions
All players belonging to the ﬁrst team squads in
each season were eligible for inclusion. Players who
were transferred to other clubs or ﬁnished their
contracts due to other reasons before the end of a
season were included for as long as they partici-
pated. Injury was deﬁned according to time loss
(table 1), and players were considered injured until
the club medical staff allowed full participation in
training and availability for match selection.
For the purpose of this study, the ankle (talocrural)
region included the tibiotalar and the inferior tibio-
ﬁbular joints as well as the surrounding stabilising
connective soft tissue (ie, joint capsules and liga-
ments) of these joints and the overlying skin.
Achilles tendon pathology was classiﬁed as lower
and, similarly, the pathology of other
tendons passing from the lower leg to the foot was
classiﬁed by the study group as lower leg or foot
injuries depending on the injury location. Ankle
sprains were classiﬁed as capsular, lateral (anterior
taloﬁbular, calcaneoﬁbular and posterior taloﬁbular
ligaments), medial (deltoid ligament) and high
(tibioﬁbular syndesmosis). Reinjuries were deﬁned
according to the concept of early recurrences.
Waldén M, et al. Br J Sports Med 2013;47:748–753. doi:10.1136/bjsports-2013-092223 1 of 6
A member of the medical or coaching staff registered individual
player exposure in minutes during all club (ﬁrst team, second
team or youth team) and national team training sessions and
matches. All injuries were recorded immediately after the event
by a club medical ofﬁcer. Injury cards and attendance records
were sent to the study group once a month. The injury card was
slightly modiﬁed during the study period in that all injuries had
to be classiﬁed as contact or non-contact injuries starting from
the 2004/2005 season and the minute of injury was recorded
for all match injuries from the 2005/2006 season. Each injury
was coded according to a modiﬁed version of the Orchard
Sports Injury Classiﬁcation System V.2.0.
Continuous data for anthropometrics were presented as the
mean with corresponding SD, and lay-off times were presented
as both mean±SD and median with corresponding IQR. Injury
rate (IR) was calculated as the number of injuries per 1000 h
with corresponding 95% CI. Injury burden was calculated as
the number of lay-off days per 1000 h. IRs were compared
using a rate ratio (RR) and signiﬁcance tested with z-statistics.
The seasonal trend for ankle injuries in general and ankle
sprains, expressed as the average annual percentage of change,
was analysed using linear regression with log-transformed IRs as
a dependent variable. A 2-year moving average (MA) approach,
by summarising two consecutive seasons, was also used to
smooth out large seasonal variation. Owing to a skewed distri-
bution, differences in lay-off times were analysed using the
Mann-Whitney U test for reinjuries and the Kruskal-Wallis test
for ankle sprain categories. Injury occurrence between the six
15 min periods of a match was analysed using the one-sample
proportional z test. All analyses were two-sided and the signiﬁ-
cance level was set at p<0.05.
A total of 8029 injuries were recorded during 1 057 201 expos-
ure hours (888 249 training and 168 952 match). There were
1080 ankle injuries (427 training and 653 match), thus constitut-
ing 13% of all injuries. The overall ankle IR was 1/1000 h (table 2),
which means that a professional football club with a 25-player
squad will suffer around seven ankle injuries in each season.
Ankle sprain was the single most common injury type (table 2),
constituting 68% of all ankle injuries and 9% of all injuries. The
overall ankle sprain rate was 0.7/1000 h (table 2), and a profes-
sional 25-player squad will thus suffer an average of four to ﬁve
ankle sprains in each season. The MA approach indicated an
average annual IR decrease of 1.7% for ankle injuries in general,
but the seasonal trend in the regression model was not signiﬁcant
=0.12, b=−0.011, 95% CI −0.034 to 0.012, p=0.30).
Similarly, an average annual IR decrease of 3.1% for ankle
sprains was indicated in the MA approach (ﬁgure 1), with a statis-
tically signiﬁcant seasonal trend in the regression model
=0.39, b=−0.030, 95% CI −0.059 to −0.002, p=0.041).
When comparing preseason and competitive season (ﬁgure 2),
there were no statistically signiﬁcant differences in ankle IRs
during training (0.51/1000 h vs 0.48/1000 h, RR 1.06, 95% CI
0.84 to 1.34, p=0.60) or match play (4.13/1000 h vs 3.81/
1000 h, RR 1.08, 95% CI 0.88 to 1.33, p=0.45), as well as in
ankle sprain rates during training (0.34/1000 h vs 0.33/1000 h,
RR 1.05, 95% CI 0.79 to 1.38, p=0.76) or match play (2.86/
1000 h vs 2.53/1000 h, RR 1.13, 95% CI 0.87 to 1.45, p=0.32).
Three-quarter of the sprains affected the lateral ligaments,
whereas only 5% were high syndesmotic injuries (table 2). More
sprains occurred to the dominant leg (542/729), and the differ-
ences in IRs between the dominant and non-dominant ankles
were statistically signiﬁcant (0.51/1000 h vs 0.18/1000 h, RR
2.90, 95% CI 2.45 to 3.42, p<0.0001). The IRs for the differ-
ent sprain categories were between 3 and 10 times higher
during match play compared with training (table 3).
Second to joint and ligament injuries, contusions were most
common and constituted approximately every sixth ankle injury,
whereas only 18 fractures were reported (table 2). Ankle
impingement syndromes were uncommon causes of time loss
(table 2). The rate of posterior impingement was more than
threefold higher than that of anterior impingement (0.024/
1000 h vs 0.007/1000 h, RR 3.57, 95% CI 1.54 to 8.26,
p=0.003). Most of the impingement syndromes affected the
dominant ankle (5/7 in anterior and 16/25 in posterior).
From season 2004/2005 and forward, 566 ankle sprains were
classiﬁed according to contact or non-contact (six cases
missing), with more than half of them being the result of player
Table 1 Operational definitions used in study
Training session Team training that involved physical activity under the supervision of the coaching staff
Match Competitive or friendly match against another team
Injury Any physical complaint sustained by a player that resulted from a football match or football training and led to the player being unable to take
full part in future football training or match play
Ankle injury Injury to the tibiotalar and the inferior tibiofibular joints as well as the surrounding stabilising connective soft tissue (ie, joint capsules and
ligaments) of these joints and the overlying skin
Slight/minimal injury Injury causing 0–3 days lay-off
Mild injury Injury causing 4–7 days lay-off
Moderate injury Injury causing 8–28 days lay-off
Severe injury Injury causing >28 days lay-off
Traumatic injury Injury with sudden onset and known cause
Overuse injury Injury with insidious onset and no known trauma
Reinjury Injury of the same type and at the same site as an index injury occurring within 2 months after return to full participation from the index injury
Non-contact injury Injury occurring without contact with another player or object
Dominant leg Preferred kicking leg
Foul play Violation of the laws of the game according to the match referee
Injury rate Number of injuries per 1000 player hours ((Σ injuries/Σ exposure hours)×1000)
Injury burden Number of lay-off days per 1000 player hours ((Σ lay-off days/Σ exposure hours)×1000)
2 of 6 Waldén M, et al. Br J Sports Med 2013;47:748–753. doi:10.1136/bjsports-2013-092223
contact (58%). Foul play (own or opponent) was involved in
40% of the match-related ankle sprains, but few of these fouls
were sanctioned with a yellow or red card (5.8%). Additionally,
the minute of injury was reported for 285 ankle sprains occur-
ring during match play from season 2005/2006 and forward (35
cases missing). Signiﬁcantly fewer ankle sprains than expected
occurred during the ﬁrst 15 min of the ﬁrst half (11.2% vs
16.7%, p=0.014), whereas no signiﬁcant differences were
detected for the rest of the 15 min periods (ﬁgure 3).
In total, 13% of the ankle injuries were severe (table 4). The
average lay-off per ankle injury was 16±27 (median 8, IQR 15)
days with the injury burden completely dominated by lateral
ligament sprain (table 4). High ankle sprains had an average
lay-off of 43±33 (median 34, IQR 37) days and this was signiﬁ-
cantly longer than the other three ankle sprain categories
(p<0.0001). Finally, there were three avulsion fractures of the
lateral malleolus causing a lay-off between 6 and 15 days,
whereas all other ankle fractures were severe with an average
lay-off of 103±45 (median 93, IQR 50) days.
Table 2 Frequency, injury rate and injury recurrence of all ankle injury types in male professional football
Number of injuries (%) IR* 95% CI Number of re-injuries (%)
Fracture and bone stress 22 (2.0) 0.021 0.014 to 0.032 1 (4.5)
Fractures 18 (1.7) 0.017 0.011 to 0.0027 1 (5.6)
Other bone stress 4 (0.4) 0.004 0.001 to 0.010 0
Joint and ligament 744 (68.9) 0.704 0.655 to 0.756 78 (10.5)
Dislocation/subluxation 3 (0.3) 0.003 0.001 to 0.009 0
Sprain/ligament injury 729 (67.5) 0.690 0.641 to 0.742 75 (10.3)
Capsular 67 (9.2) 0.063 0.050 to 0.081 5 (7.5)
Lateral 552 (75.7) 0.522 0.480 to 0.568 58 (10.5)
Medial 72 (9.9) 0.068 0.054 to 0.086 8 (11.1)
High 38 (5.2) 0.036 0.026 to 0.049 4 (10.5)
Cartilage lesion 12 (1.1) 0.011 0.006 to 0.020 3 (25.0)
Contusion 182 (16.9) 0.172 0.149 to 0.199 0
Laceration and skin lesion 10 (0.9) 0.010 0.005 to 0.018 1 (10.0)
Peripheral nervous system 2 (0.2) 0.002 0.001 to 0.008 0
Other 120 (11.1) 0.114 0.095 to 0.136 41 (34.2)
Synovitis 65 (6.0) 0.062 0.048 to 0.078 26 (40.0)
Impingement 32 (3.0) 0.030 0.021 to 0.043 4 (12.5)
Anterior 7 (0.6) 0.007 0.003 to 0.014 2 (28.6)
Posterior 25 (2.3) 0.024 0.016 to 0.035 2 (8.0)
Instability 7 (0.6) 0.007 0.003 to 0.014 3 (42.9)
Unspecified pain 12 (1.1) 0.011 0.006 to 0.020 3 (25.0)
Osteoarthritis 2 (0.2) 0.002 0.001 to 0.008 0
Sinus tarsi syndrome 2 (0.2) 0.002 0.001 to 0.008 1 (50.0)
Total 1080 (100) 1.022 0.962 to 1.084 121 (11.2)
*Injury rate (IR) is expressed as the number of injuries per 1000 h.
Figure 2 Seasonal distribution of injury rates in male professional
football. Injury rate is expressed as the number of injuries per 1000 h.
Figure 1 Injury rates for ankle sprain per season. Injury rate is
expressed as the number of injuries per 1000 h. The dark grey line
shows the 2-year moving average injury rate calculated as the sum of
two consecutive seasons.
Waldén M, et al. Br J Sports Med 2013;47:748–753. doi:10.1136/bjsports-2013-092223 3 of 6
In total, 11% of all ankle injuries and 10% of ankle sprains
were classiﬁed as reinjuries (table 2). No signiﬁcant difference in
average lay-off was seen between recurrent sprains and other
sprains (15±19 (median 9, IQR 13) vs 15±21 (median 8, IQR
15 days), p=0.87).
The principal ﬁnding of this study was that 40% of the
match-related ankle sprains occurred as a result of foul play.
Other important ﬁndings were that almost every 10th football
injury was an ankle sprain and that the ankle sprain rate showed
a statistically signiﬁcant decreasing trend over the 11-season
study period. Finally, ankle impingement was an uncommon
cause of time loss during the seasons studied, especially the
Ankle injury epidemiology
In a large-scale review of 227 studies on 70 different sports
ball was a high-risk sport for ankle injury, particularly ankle sprain.
We found that 68% of all ankle injuries were sprains and this
ﬁnding extends the previous literature.
Historically, ankle sprain
used to be the most common football injury and studies from male
high-level football conducted during the 1980s and 1990s
reported overall ankle sprain rates as 1.8/1000 h and 1.3/1000 h,
In more recent studies conducted from 1999 and
later, however, the ankle sprain rate has been considerably lower
The overall ankle sprain rate in the
current study was 0.7/1000 h, and it thus seems that the current
ankle sprain rate is lower than that historically attributed.
Interestingly, there was a trend of a further decline over time with
an average annual decrease in the ankle sprain rate of 3%.
The most plausible explanation to the lower ankle sprain rate
nowadays and the declining trend is successful implementation
of strategies in the clubs such as balance board training and
taping/bracing for preventing recurrent ankle sprains,
although no such player data were collected in this study.
Another contributing factor could be that more training now
than before is devoted to ‘low-risk’ activities such as recovery
sessions, resistance training and physical conditioning, making
the overall ankle sprain rates lower.
Foul play was involved in 40% of the match play ankle
sprains. This ﬁnding is in line with the results in a previous sys-
tematic video analysis study of Norwegian and Icelandic elite
football where many ankle sprains were shown to result from
late tackles, sometimes even intentional fouls, without penalty
to the offending player.
We therefore call for stricter enforce-
ment of the existing rules or introduction of new rules such as
timed suspensions to be able to prevent these frequent
contact-related injuries that theoretically would be very difﬁcult
to prevent with balance training or ankle support.
Ankle sprain frequency at different stages of matches
In two studies on male professional and amateur football, ankle
sprains were more frequent in the last thirds of both halves,
without formal statistics, whereas no such trend was detected in
the current study.
No worries for footballer’s ankle?
Although given increasing attention in recent years,
and posterior ankle impingement syndromes were quite infre-
quent in this study and constituted only 3% of all ankle injuries.
Considering that anterior ankle impingement historically was
called ‘footballer’s ankle’,
the posterior impingement rate
was, somewhat surprisingly, more than threefold higher in the
current study. The problem with ankle impingement is, however,
most probably underestimated due to the use of a time loss injury
and players might be able to play despite their symp-
toms and are perhaps not referred to deﬁnitive treatment until
the season is over. As only 4 of the 32 impingement injuries in
Table 3 Match and training injury rates for the most common ankle injury types in male professional football with corresponding rate ratios
Match IR* 95% CI Training IR* 95% CI RR† 95% CI
All ankle injuries 3.865 3.580 to 4.173 0.481 0.437 to 0.529 8.04 7.12 to 9.08
Fractures 0.065 0.036 to 0.112 0.008 0.004 to 0.118 8.26 3.20 to 21.31
Sprain/ligament injury 2.581 2.350 to 2.835 0.330 0.294 to 0.370 7.82 6.75 to 9.07
Capsular 0.160 0.110 to 0.233 0.045 0.033 to 0.061 3.46 2.13 to 5.63
Lateral 2.024 1.821 to 2.251 0.236 0.207 to 0.271 8.56 7.21 to 10.17
Medial 0.249 0.184 to 0.336 0.034 0.024 to 0.048 7.36 4.61 to 11.58
High 0.148 0.100 to 0.219 0.015 0.009 to 0.025 10.11 5.17 to 19.73
Contusion 0.817 0.691 to 0.965 0.050 0.037 to 0.067 16.49 11.74 to 23.15
Synovitis 0.142 0.095 to 0.212 0.046 0.034 to 0.063 3.08 1.86 to 5.09
Impingement 0.095 0.058 to 0.155 0.018 0.011 to 0.029 5.26 2.63 to 10.51
Anterior 0.024 0.009 to 0.063 0.003 0.001 to 0.011 7.01 1.57 to 31.32
Posterior 0.071 0.040 to 0.125 0.015 0.009 to 0.025 4.85 2.21 to 10.64
*Injury rate (IR) is expressed as the number of injuries per 1000 h.
†Rate ratio is expressed as the match injury rate divided by the training injury rate.
Figure 3 Proportion of ankle sprains during the 15 min periods of
match play in male professional football.
4 of 6 Waldén M, et al. Br J Sports Med 2013;47:748–753. doi:10.1136/bjsports-2013-092223
the current study were categorised as severe, most of them were
obviously managed non-surgically in this setting.
Interestingly, almost two-thirds of the impingements occurred
to the preferred kicking leg (dominant ankle) in the current
study. It has previously been shown that a typical ankle injury
mechanism in football is a forced plantar ﬂexion where the
injured player hit an opponent’s foot when attempting to shoot
or clear the ball, and this anterior capsular traction mechanism
was suggested to contribute to the development of ‘footballer’s
However, since the anterior joint capsule attachments
are more proximal and distal to the sites where the talotibial
spurs originate, this theory has been questioned.
It is note-
worthy that a forced plantar ﬂexion not only leads to an anter-
ior traction force, but also to a forceful compression of the
bony and soft tissues on the posterior part of the ankle.
the previously described injury mechanism for ‘footballer’s
ankle’ could therefore be a more common cause of posterior
ankle impingement. This notion is supported by the fact that
posterior impingement was signiﬁcantly more common in the
current study than anterior impingement.
In total, 87% of the ankle sprains had a lay-off of less than
4 weeks, which is in line with a recent study from Swedish elite
football where this ﬁgure was 83%.
The mean lay-off per ankle
sprain was, however, 15 days in the current study compared with
only 8 days in that study. This apparent discrepancy could pos-
sibly reﬂect a ‘better safe than quick’ treatment algorithm that is
supported by the fact that the ankle sprain reinjury frequency
was low (10%).
Interestingly, almost two-thirds of the high ankle sprains were
severe and these injuries were associated with a substantially
longer lay-off than both the lateral and medial ligament sprains.
The athletic literature in this ﬁeld is scarce, but in a review of
1344 ankle sprains occurring in West Point cadets, only 10 high
ankle sprains were identiﬁed, but, in line with the current study,
these injuries required a considerably longer time to return to
full activity compared with grade III lateral ligament sprains
(mean 55 vs 28 days).
The prospe ctive design with rigorous data check-up and the
11-season study period to avoid the inﬂuence of occa sional
extreme seasons are some important strengths of the present
study together with the large a nd homogeneous sample of pro-
fessional foo tballers. However, this study also has some
important limitations. First, no treatment details were
requested on the general injury card, and additionally, no sub -
study speciﬁ c injury card was sent to the clubs as for some of
our previous substudies.
It would h ave been interestin g to
collect surgical data for the ankle fractures and impingement
syndromes, but it would prob ably be of minor value for ankle
sprains since the need for ligament surgery in professional
football has been shown to be minimal.
Second, no informa-
tion about the use of any preventive training such as balance
board training and coach-directed limitation o f p layer-contact
during training session s or the use of any protective equipment
such as bracing and taping was recorded, and these aspects
the re fore need to be addressed in future studies. Third, only
one diagnosis was recorded for each injury case in the database
(the main di agnosi s). In cases with multiple injuries s ustained
in the same even t (eg, a severe ankle ligament sprain with con-
comitant mild cartilage abnormalities on imaging), only the
most signiﬁcant injury i s captured in the injury surveillance.
Fourth, all tendon injuries were excluded from the deﬁnition
of ankle injury, and it could be argued that, for example, pos-
terior tibial and peroneal tendon injuries located posterior to
the malleoli should be included amo ng the ankle injuries. The
exact location of the tendon pathology was, however, not
requested on the injury card and the tendo n injuries were
therefore excluded from the ankle injury deﬁnition. Fifth, the
par tici pating clubs were not provided with any speciﬁcdiag-
nostic or return-to-play criteria in our study manual, and it is
therefore possible that the reported subclassiﬁcations, lay-off
times and reinjury frequency varied between clubs due to the
different diagnostics and treatment algorithms. Sixth, no reli-
able history of previous injury was collected at player inclu-
sion, and i t was the refore not possible to com pare the ankle
sprain rates between uninjured players and players with prior
ankle sprain. It is, however, well kn own that players with pre-
vious ankle sprain during the career or the preceding season
have approximately 2–3 times higher rate of future ankle
Finally, the design of the injury card during the
ﬁrst seasons of the study did not include information about the
match minute of the injury and whether it resulted from
contact or not.
Table 4 Severity, lay-off and injury burden for the most common ankle injury types in male professional football
0–3 days* 4–7 days* 8–28 days* >28 days* Mean lay-off† SD Median lay-off† IQR Injury burden‡
All ankle injuries 270 311 360 139 15.9 27.1 7 13 16.3
Fractures 0 0 3 15 89.6 52.0 87 70 1.5
Sprain/ligament injury 141 212 279 97 15.4 20.5 8 15 10.6
Capsular 29 27 9 2 7.3 13.3 4 3 0.5
Lateral 100 157 233 62 14.7 19.2 8 14 7.7
Medial 11 26 26 9 13.6 15.4 7 12 0.9
High 1 2 11 24 43.2 33.0 34 37 1.6
Contusion 84 61 33 4 6.2 10.3 4 5 1.1
Synovitis 22 17 20 6 16.0 39.6 7 11 1.0
Impingement 11 8 9 4 12.1 16.4 6.5 8 0.4
Anterior 1 1 3 2 24.0 24.7 11 41 0.2
Posterior 10 7 6 2 8.8 11.9 5 7 0.2
*Injury severity is categorised according to lay-off days as slight/minimal (0–3), mild (4– 7), moderate (8–28) and severe (>28).
†Lay-off is expressed in days.
‡Injury burden expressed as the number of lay-off days per 1000 h.
Waldén M, et al. Br J Sports Med 2013;47:748–753. doi:10.1136/bjsports-2013-092223 5 of 6
Clinical and policy implications—call for action
In conclusion, lateral ligament ankle sprains constituted half of
all ankle injuries in male professional football, whereas the
anterior and posterior ankle impingement syndromes were infre-
quent. The ankle sprain rate showed a statistically signiﬁcant
decreasing trend over the 11-season study period, and although
the reasons for this cannot be ascertained from our study
design, it is consistent with a decreasing trend for ligament
injuries in general.
Many match-related ankle sprains were,
however, associated with foul play and this ﬁnding might
warrant a discussion in the international governing bodies about
stricter rule enforcement.
What this study adds
▸ The ankle sprain rate in male professional football has
decreased signiﬁcantly over the past decade.
▸ Foul play was involved in more than half of the ankle
sprains associated with player contact.
▸ Ankle impingement syndromes, especially the anterior
‘footballer’s ankle’, were uncommon causes of time loss.
How might it impact on clinical practice?
Ankle sprains are common and constitute more than half of all
ankle injuries in professional football. The decreasing trend in
the ankle sprain rate since 2001/2002, as shown in this study,
gives indirect evidence that injury prevention strategies have
been successful. These ﬁndings might therefore serve as a
motivator among players, coaches, medical practitioners and
stakeholders for continuous preventive efforts in the sport.
Acknowledgements The authors would like to thank the participating clubs
(coaching and technical staff, medical teams and players) for their participation in
the study. Henrik Magnusson, MSc, is also acknowledged for statistical advice.
Contributors MW, MH and JE were responsible for the conception and design of
the study. All authors have been involved in the data collection over the study
period. MW and the statistical advisor conducted the analyses which were planned
and checked with the coauthors. All authors contributed to the interpretation of
ﬁndings and had full access to all data. MW wrote the ﬁrst draft of the paper which
was critically revised by MH and JE. The ﬁnal manuscript has been approved by all
authors. MW is the study guarantor.
Funding This study was funded by grants from the Union of European Football
Associations (UEFA), Swedish National Centre for Research in Sports, and
Competing interests JE is the ﬁrst vice chairman of the UEFA Medical
Ethics approval The study design was approved by the UEFA Medical Committee
and the UEFA Football Development Division.
Provenance and peer review Not commissioned; externally reviewed.
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