The sixth edition of the FIFA Women’s World Cup™ this year will give the best female players from across the globe another opportunity to showcase just how far the sport has developed in terms of skill levels, tactical astuteness and physical prowess. But medical experts are also hoping it will offer a chance to reverse the increasing number of injuries being sustained by top women players.

Since 1998, the FIFA Medical Assessment and Research Centre (F-MARC) has been asking team doctors attending all FIFA women’s competitions to hand in a detailed injury report after each game, setting out not only the type of injuries sustained, but also describing how they happened, for example whether due to contact with another player or foul play.

The collated data from these reports now comprises a considerable body of injury statistics from no fewer than 13 women’s international elite competitions (three FIFA Women’s World Cups, three Women’s Olympic Football Tournaments and seven youth championships).

Overall, the figures show that average injury rates in women’s football are still slightly below those in the men’s game – 2.3 per match compared to 2.5 for the men. But unlike the men’s game, which has seen a steady decrease in injury rates over recent years, the women’s game has seen rates rising.

Indeed, there has been a continuous upward trend in injury frequency at all FIFA women’s competitions, both for the total number of injuries and for the number of more severe “time-loss” injuries, defined as those which cause players to miss at least one subsequent match or training session.

It is worth remembering that the general nature of football injuries tends to be mild, a conclusion backed up by the F-MARC data. In about two-thirds of the recorded women’s injuries, the players were able to play on after the incident. Even in the remaining one-third of “time-loss injuries”, the statistics from the international tournaments showed that the vast majority of these injuries were minor (defined as when the player was out injured for seven days or less).

Looking solely at the FIFA Women’s World Cup, injury rates have consistently risen during the past three editions (starting with an average of 1.3 injuries per match in 1999, reaching 1.7 in 2003 and climbing to 2.3 in China PR four years ago). By way of contrast, the men’s FIFA World Cup™ has seen injury rates fall from an average of 2.7 in 2002 to 2.3 in 2006 before breaking below the symbolic fi gure of two injuries per game when the 32 teams participating in the 2010 FIFA World Cup South Africa™ recorded an overall average of 1.9 injuries per match.

Athleticism equals injuries?Of course, the aforementioned increase in physical fitness, speed and athleticism among the leading women players may have had a contributory effect on the increase in injuries, but FIFA’s medical experts point out that any such correlation is so far unproven, and may indeed be oversimplistic, particularly when set against the falling injury rates among the top men’s players.

“The increased speed and dynamics of play might contribute to this finding, but they probably cannot fully explain it,” stated Prof. Jiri Dvorak, FIFA Chief Medical Officer. “Injuries are generally caused by a multitude of factors that we need to consider.”

With that in mind, F-MARC has concentrated its studies not just on the frequency but also on all aspects of the players’ injuries. By identifying the precise nature of the most common injuries and seeing how they happened, the aim is to produce a body of medical evidence which can be used to reduce such injury rates in future.

Players can reduce the risk of injury by introducing into their conditioning programmes elements of strength, balance, agility and core stability work. This must become a natural part of their training routine.

When it comes to the location on the body of injuries sustained by women footballers in international competition, about two-thirds of these were to the leg, especially the ankle, knee and thigh, with the next most common injury being to the head. While these findings are in line with patterns seen among the men, there is a difference with regard to the type of injury in that women appear to sustain more concussion and knee ligament injuries than their male counterparts. Anterior cruciate ligament (ACL) injuries, in particular, seem to occur up to ten times more often in women than in men, while an ankle sprain is the single most diagnosed injury in female players.

Just as important as identifying the types of injuries is the need to determine the manner in which they occurred, especially in regards to reducing future injury rates. Based on the team doctors’ reports, the clear majority (about 80 per cent) of injuries at FIFA women’s competitions come from tackling and other forms of contact, with only around 20 per cent occurring without any contact with another player.

Assistance requiredWith contact injuries forming such a lion’s share of the total injury figures, FIFA’s medical experts are reliant on players, coaches and referees to promote fair play and work together to eliminate especially dangerous fouls, such as elbowing and two-footed sliding tackles from behind or the side (see 'Four golden rules of injury prevention').

Teams can also play a part in reducing injuries before games have even begun, however, with the use of football-specific warm-up programmes particularly effective when it comes to reducing non-contact injuries. Fortunately, it is no longer just the team doctors who understand this, with coaches and players also becoming more and more aware that properly executed injury prevention programmes can help to not only keep squads healthier but also keep the players fit and available to the coach throughout lengthy campaigns and tournaments.

“We are seeing an ever-increasing number of injuries in the women’s game,” pointed out Hope Powell, the head coach of England’s national women’s team. “It is therefore essential to recognise the demands that the game places on the body. Players can reduce the risk of injury by introducing into their conditioning programmes elements of strength, balance, agility and core stability work. This must become a natural part of their training routine.”

FIFA’s own '11+' programme has been developed to achieve exactly that. Designed as “a complete warm-up to prevent injuries”, the programme has already shown remarkable results. In one test involving almost 2,000 female youth players, for example, it was found that performing the '11+' at least twice a week led to a 30-50 per cent reduction in injured players compared to teams that had warmed up using their usual methods.

One area in which the '11+' could have a particularly telling long-term effect is in reducing the previously mentioned prevalence of ACL injuries among women footballers, in particular. Complete ACL tears can keep players out injured for more than six months and can also often lead to long-term problems, including early osteoarthritis. And yet 70 per cent of tears are non-contact injuries, caused by typical movements in football such as sudden one-step deceleration, sudden changes of direction or landing from a jump with the knee and hip extended.

The '11+' teaches players how to perform such moves in a way that decreases their risk of injury. As already explained, however, a dramatic reduction in injuries can only be achieved if medics, players, coaches and referees work together to minimise both the contact and non-contact varieties of injury.

“Whatever the main reasons for this rise in injuries among women footballers, we must do everything we can to reverse the trend,” concludes Dr Michel D’Hooghe, chairman of the FIFA Medical Committee and FIFA Executive Committee member. “We want women to enjoy the benefits of the game, and not suffer from the downsides. And thanks to F-MARC’s research, we can today give them the means to protect themselves.”

Thanks to the multifaceted and joint approach advocated by FIFA’s medical experts, it can at least be hoped that this year’s FIFA Women’s World Cup will finally see the start of a downward trend in the frequency of women’s injuries.

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