Hip and groin injury is the most common non-time-loss injury in female amateur football

Hip and groin injury is the most common non-time-loss injury in female amateur football Purpose Hip and groin injuries in football are problematic due to their high incidence and risk of chronicity and recurrence. The use of only time-loss injury definitions may underestimate the burden of hip and groin injuries. Little is known about hip and groin injury epidemiology in female football. The first aim of this study was to examine the within-season (2014–2015) prevalence of total injury with and without time-loss in female amateur football players. The second aim was to study the within-season and preseason (2015–2016) prevalence of hip/groin injuries with and without time-loss. The third aim was to study the association between the duration of hip and groin injury in the 2014–2015 season and the severity of hip/groin problems during the 2015–2016 preseason. Methods During the preseason, 434 Dutch female amateur football players completed an online questionnaire based on the previous season and current preseason. The hip and groin outcome score (HAGOS) was used to assess the severity of hip and groin injuries. Results The hip/groin (17%), knee (14%), and ankle (12%) were the most frequent non-time-loss injury locations. The ankle (22%), knee (18%), hamstring (11%), thigh (10%), and hip/groin (9%) were the most common time-loss injury locations. The previous season prevalence of total injury was 93%, of which non-time-loss injury was 63% and time-loss injury was 37%. The prevalence of hip/groin injury was 40%, non-time-loss hip/groin injury was 36% and time-loss hip/groin injury was 11%. The preseason prevalence of hip/groin injury was 27%, non-time-loss hip/groin injury was 25%, and time-loss hip/ groin injury was 4%. Players with longstanding hip/groin injury (> 28 days) in the previous season had lower HAGOS scores at the next preseason than players with short-term (1–7 days) or no hip/groin injury (p < 0.001). From all players with hip/ groin injury from the previous season, 52% also sustained hip/groin injury in the following preseason, of which 73% were recurrent and 27% were chronic hip/groin injuries. Conclusion Injury risk, and especially non-time-loss hip and groin injury risk, is high in female amateur football. Three- quarters of the players with longstanding hip and groin injuries in the previous season have residual problems at the start of the following season. Level of evidence II. Keywords Female football (soccer) · Female athlete · Groin pain · Hip and groin injury Introduction The number of female football players in Europe is growing rapidly, and female participation rates in the US almost equal those of males [28]. Dutch female football has increased Electronic supplementary material The online version of this rapidly, with 23% more players over the past 5 years and article (https ://doi.org/10.1007/s0016 7-018-4996-1) contains supplementary material, which is available to authorized users. 153,001 registered players in the 2016–2017 season. It is now the largest female team sport in Holland [28]. * Rob Langhout Despite its popularity and growth, injury studies in langhout.rob@gmail.com female football lag far behind those in male football [21]. In Extended author information available on the last page of the article Vol.:(0123456789) 1 3 Knee Surgery, Sports Traumatology, Arthroscopy addition, most injury or risk factor studies use only time-loss Participants injury (TLI) definitions [7 , 30]. The within-season preva- lence of TLI in elite female football ranges between 38 and All participants were female amateur players in the Dutch 48% [4, 6, 10, 11, 14, 15, 20]. Non-time-loss injury (NTLI) women’s football league, as registered by the Royal Dutch has been less studied in football [30]. The little available Football Association (KNVB). To obtain a large sample data suggest, as expected, that NTLI is more common than size, 43 teams (645 players), representing all amateur play- TLI [9, 17]. ing levels (top class, sub-top class, 1st–6th class) from all Studies reporting specifically on hip and groin injury KNVB districts were selected and invited by e-mail to par- (HGI) are hard to compare, as they use different injury ter - ticipate in this general injury survey. Every player received minologies and definitions [ 2, 32]. A study in elite female information by e-mail about the study and instructions for football players found that injury rates were four times completing the questionnaire (Supplementary Appendix). higher (36 vs. 9%) for non-time-loss HGI (NTL-HGI) than Players were included if they were female, were between for time-loss HGI (TL-HGI) [9]. A recent systematic review the ages of 18 and 40, and had played amateur football showed that, in elite female studies, prevalence rates of during the previous season, regardless of being injured TL-HGI ranged from 2 to 11% [30]. The use of TL-HGI or not. Professional players and those from the veteran’s definitions probably underestimates the true burden of HGI leagues were excluded. The parameters of age, height, [7, 26]. HGI is common in (sub-) elite male football and is weight, weekly average exposure (training and matches), known for its high incidence, chronicity, and risk of recur- leg dominance (defined as the preferred kicking leg), and rence [19, 26, 34]. Injury risk and prevention has yet not playing levels were self-reported. been studied in female amateur football players [30]. Patient-reported outcome measures (PROs) are the gold standard for assessing the perceived health status of spe- Injury registration cific populations and injuries [16]. The hip and groin out- come score (HAGOS) is developed for young and active Time-loss injury (TLI) was defined as ‘Any physical com- individuals, measures the severity of hip- and groin-related plaint sustained by a player as a result of a football match problems, and is validated in several languages, including or training, resulting in a player being unable to fully take Dutch [23, 25, 27]. part in future football training or match play’ [7]. Non- Limited literature exists on female football players and time-loss injury (NTLI) was defined as a situation where especially on the hip/groin injuries. Most literature on this players experienced ‘Any physical complaint as a result topic studied professional players, although the amount of of a football match or training, but without time-loss’ [7]. amateur football players is the majority of the people that The same definitions applied for hip and groin injury, visit the sports clinic. Therefore, the first aim of this study referring to NTL-HGI and TL-HGI. The presence of injury was to examine the within-season (2014–2015) prevalence was scored by dichotomous answer options (yes/no). of total injury burden (NTLI and TLI) in female amateur When present, the duration (days) of both NTL-HGI football. The second aim was to study the within-season and and TL-HGI was noted and classified as minor (1–7 days), preseason (2015–2016) prevalence of hip and groin injury moderate (8–28 days), or major (> 28 days), according to (NTL-HGI and TL-HGI). The third aim was to examine the the international classification for football injuries [7 ]. In association between the duration of HGI in the 2014–2015 addition, the manner of onset (maximal kicking, sprinting/ season and the severity of hip/groin problems during the running, cutting/pivoting, and other) of HGI was regis- 2015–2016 preseason. tered for the 2014–2015 season. An online registration system was used (Google Forms). Materials and methods Injury region In this cross-sectional survey study, female amateur foot- A body chart was used to illustrate all locations of NTLI ball players completed an online questionnaire during the and TLI based on the Dutch Injury Information System 2015–2016 preseason. The ‘Strengthening the Reporting of framework and Orchard Sports Injury Classification Sys- Observational Studies in Epidemiology’ (STROBE state- tem [18]. For this study, the hip/groin was referred to as ment) was used to report the findings of this study [29]. ‘the region between the front of the hip and the inner front By clicking the “I participate” link in the electronic ques- of the thigh’ [18]. A chart of the hip and groin region was tionnaire, the participants gave their consent that their used to address the location of HGI in this region. anonymized data could be used for research purposes. 1 3 Knee Surgery, Sports Traumatology, Arthroscopy Hip and groin outcome score (HAGOS) Statistical analysis The HAGOS was used to assess the severity of hip- and The data were tested for normality using the Kolmogo- groin-related problems for all players on six subscales: pain rov–Smirnov test. Normally distributed data are presented (P), symptoms (S), activities of daily living (ADL), sport as a mean and standard deviation (SD). Non-normally dis- and recreation (SR), participation in physical activities (PA), tributed data are presented as a median and interquartile and quality of life (QOL) [27]. Subscale scores range from 0 range (IQR 25–75%). The presence and locations of NTLI to 100, where 0 indicates severe hip and groin symptoms and and TLI are presented as absolute (counts) and relative (per- problems, and 100 indicates no symptoms or problems [27]. centage of total). To avoid overestimation, HGI was defined HAGOS is available in the Dutch language and is found to as the total number of players with NTL-HGI and TL-HGI be reliable (ICCs between 0.83 and 0.87), internally consist- minus the number of players with both injuries. The duration ent (Cronbach’s α between 0.81 and 0.92), valid in young (days) of NTL-HGI and TL-HGI was analysed by frequen- athletes (including football players), and comparable to the cies and percentage of the total number of players. The aver- original Danish version [23]. The mean ± SD test–retest dif- age number of players for an average squad was calculated ferences for the six subscales were 0.5 ± 10.9 (P), 1.7 ± 10.4 to examine the number of injuries per squad per season. (S), 0.4 ± 14.2 (ADL), 2.8 ± 15.8 (SR), 2.3 ± 18.9 (PA), and To calculate duration (days) of NTL-HGI and TL-HGI per 2.5 ± 11.5 (QOL). squad, an arbitrary duration of 3 days was chosen for minor HGI, 18 days for moderate HGI, and 28 days for major HGI, Survey period to prevent overestimation. Match and training exposure were determined (hours) Participants were asked to complete the injury question- and 1 match represented 1.5 h. A Mann–Whitney U test naire (including HAGOS) during an 8-week period in the was used to examine differences between HAGOS scores preseason of 2015–2016 (August, September, and October for HGI, no HGI, and HGI duration groups. Incorrect or 2015). NTLI and TLI were retrospectively assessed per body missing data were reported and corrected by the means of location for the previous season (1 August 2014–15 June the variables and frequencies. The level of significance was 2015). NTLI-HGI and TL-HGI were assessed for the previ- set at α < 0.05. The data were analysed using SPSS 23 (IBM, ous season and for the current preseason. History of HGI Armonk, USA). was assessed for the period prior to the 2014–2015 season. The HAGOS scores concerned the player’s health status for the week prior to completing the questionnaire (see the Sup- Results plementary Appendix for the survey and HAGOS at http:// www.koos.nu). Of the 43 teams invited, 8 teams (120 players) declined the Bias invitation and 35 teams participated in this study (response rate 81%). This resulted in 525 female players, from which To minimize recall bias, dichotomous answer options, defi- 91 (17%) failed to meet the inclusion criteria of being at least 18 years of age (n = 89) or participating in the included nitions of the terms used, and assisting figures that specified anatomical regions were employed [16]. Adequate reliability playing levels (n = 2 veterans league). Data from 434 players were used for the analysis (Fig. 1). between retrospective and prospective dichotomous registra- tion of self-reported injuries has been previously observed During the previous season, the 434 players had a total exposure time of 64,034  h (50,720 training and 13,314 [3]. match hours). On average, each player spent 148 ± 58  h playing football (117 ± 54 training and 31 ± 12 match hours) Approval during the 40-week competitive season. An average team consisted of 14.7 ± 0.7 players. Player characteristics are This study complied with the requirements of the declaration of Helsinki [35]. The Dutch Central Committee on Research shown in Table 1. Involving Human Subjects (CCMO) states that no medical ethical approval was necessary for this questionnaire study. Total injury during the previous season Participants were neither physically examined nor treated by any means. As such no burden existed nor were they denied For the previous season, 404 players (93%) reported 1439 any treatment. This is stated in the Dutch Medical Research Involving Human Subjects Act (WMO; http://wette n.overh injuries, of which 904 (63%) were NTLI and 535 (37%) were TLI. Most injured players had one NTLI (n = 136, eid.nl/ BWBR0009408). 1 3 Knee Surgery, Sports Traumatology, Arthroscopy Fig. 1 Flowchart showing player inclusion and exclusion 31%) or one TLI (n = 175, 40%) (Table  2). An average Table 1 Player characteristics (n = 434) squad of 15 players can expect 49 injuries (31 NTLI and 18 TLI) per season. Age (years) 24.2 (5.1; 18–52) The most affected NTLI locations were the hip/groin Height (cm) 170.7 (6.0; 155–190) (17%), knee (14%) and ankle (12%). The most affected TLI Weight (kg) 66.4 (8.7; 46–110) locations were the ankle (22%), knee (18%), hamstring ) 22.6 (2.7; 17.1–40.0) Body mass index (kg/m (11%), thigh (10%), and hip/groin (9%) (Table 3). Of all Match exposure (total matches per season) 20.9 (8.7; 0–60) 1439 injuries, 1261 (88%) were located in the lower body Training exposure (hours per week) 3.0 (1.4; 0–12) (including lumbar spine and pelvis). Playing level, n (%)  Top class 23 (5)  Sub-top class 48 (11) Hip and groin injury during the previous season  First class 60 (14)  Second class 51 (112) For the previous season, 172 players (40%) reported 200  Third class 35 (8) HGI. Of these 172 players, 28 players (6%) had both  Fourth class 95 (22) NTL-HGI and TL-HGI, 126 players (30%) sustained only  Fifth class 89 (21) NTL-HGI, and 18 players (4%) sustained only TL-HGI.  Sixth class 33 (8) The prevalence of NTL-HGI was 36% (154 injuries) and Leg dominance, n (%) prevalence of TL-HGI was 11% (46 injuries) (Table 4). A  Left 45 (10) history of HGI prior to the 2014–2015 season was reported  Right 389 (90) in 166 players (38%). Of those, 101 players (23%) also HAGOS subscales sustained HGI in the 2014–2015 season.  Pain (P) 100.0 (90.0–100.0) The dominant leg was affected in 100 players (58%),  Symptoms (S) 89.3 (78.6–100.0) and the non-dominant leg was affected in 33 players  Activities of daily living (ADL) 100.0 (95.0–100.0) (19%); 39 players (23%) sustained bilateral HGI. The onset  Sports and recreation (SR) 100.0 (87.5–100.0) for HGI was maximal kicking (24%), sprinting/running  Participation in physical activity (PA) 100.0 (75.0–100.0) (21%), pivoting/cutting (11%), and others (44%). An aver-  Quality of life (QOL) 100.0 (85.0–100.0) age amateur squad of 15 players can expect 5 NTL-HGIs Player characteristic presented as the mean (SD, range) or median and 2 TL-HGIs per season, resulting in 53 days of ongoing (IQR 25–75). Exposure is presented for the previous season (2014– hip and groin problems and 21 days of play lost. 2015) y years, cm centimetre, kg kilogram, kg/m kilogram/square metre, IQR interquartile range, n number 1 3 Knee Surgery, Sports Traumatology, Arthroscopy Table 2 Injury frequency (NTLI and TLI) in the previous season, presented per player (n, %) Players, NTLI n (%) 56 (13) 136 (31) 109 (25) 67 (15) 27 (6) 13 (3) 16 (4) 5 (1) 2 (1) 1 (0.2) 2 (0.8) 434 (100) Injury numbers, n 0 1 2 3 4 5 6 7 8 9 10 Total Players, TLI, n (%) 109 (25) 175 (40) 103 (24) 36 (8) 10 (2) – 1 (1) – – – – 434 (100) NTLI non-time-loss injury, TLI time-loss injury, n number Table 3 Injury location and ranking Table 4 Prevalence of hip and groin injury Non-time-loss Injury (NTLI) Time-loss Injury (TLI) Previous Season Preseason Body location Rank n (%) Body location Rank n (%) Players with HGI 172 (40) 117 (27) Players with NTL-HGI 154 (36) 109 (25) Hip/Groin 1 154 (17) Ankle 1 118 (22)  Duration Knee 2 123 (14) Knee 2 94 (18)   Minor (1–7 days) 98 (22) 71 (16) Ankle 3 110 (12) Hamstring 3 57 (11)   Moderate (8–28 days) 28 (7) 28 (7) Lumbar spine 4 92 (10) Thigh 4 52 (10)   Major (> 28 days) 28 (7) 10 (2) Thigh 5 83 (9) Hip/groin 5 46 (9) Players with TL-HGI 46 (11) 23 (5) Hamstring 6 69 (8) Lumbar spine 6 40 (8)  Duration Calf 7 59 (7) Calf 7 33 (6)   Minor (1–7 days) 22 (5) 14 (3) Foot 8 43 (5) Foot 8 24 (4)   Moderate (8–28 days) 11 (2) 2 (1) Shoulder 9 39 (5) Head 9 14 (2)   Major (> 28 days) 13 (3) 7 (2) Neck 10 30 (3) Lower leg 10 13 (2) (front) Self-reported prevalence of HGI (both non-time-loss and time-loss) Lower leg 11 29 (3) Wrist/hand 11 12 (2) in the previous season (2014–2015) and preseason of 2015–2016 (front) (n = 434) is also reported for all duration groups. Data are presented Wrist/hand 12 22 (2) Shoulder 12 10 (2) as numbers (n) and rates (%) Head 13 20 (2) Pelvis 13 9 (1) HGI hip and groin injury, NTL-HGI non-time-loss hip and groin injury, TL-HGI time-loss hip and groin injury Pelvis 14 13 (1) Trunk 14 6 (1) Trunk 15 8 (1) Neck 15 4 (1) Elbow 16 6 (0.6) Face 16 2 (0.8) previous season had lower HAGOS scores in the preseason Face 17 4 (0.4) Elbow 17 1 (0.2) than those with minor HGI (p < 0.001) (Table 5). Total 904 (100) 535 (100) Duration of hip and groin injury Body location and ranking of non-time-loss (NTLI) and time-loss injuries (TLI) for all players (n = 434) in the previous season (n, %) From the 172 players with HGI in the previous season, 82 (48%) had recovered and 90 (52%) sustained HGI in the following preseason. Of these, 66 (73%) were recurrent and Hip and groin injury during the preseason 24 (27%) were chronic HGI. There were 50 recurrent HGI (47%) from the minor HGI group in the previous season and During the preseason, 117 players (27%) reported 132 HGIs. Of these 117 players, 15 (3%) had both NTL-HGI and TL- 16 (52%) from those with moderate HGI. The 24 chronic HGIs originated from the major HGI group (71%) in the HGI, 94 players (22%) sustained only NTL-HGI, and 8 play- ers (2%) sustained only TL-HGI. The prevalence of NTL- previous season. Of the 117 HGIs in the preseason, 27 (23%) were new HGIs (Fig. 2; Table 4). HGI was 25% (109 injuries) and prevalence of TL-HGI was 5% (23 injuries) (Table 4). The dominant leg was affected in 60 players (51%), and the non-dominant leg was affected in 28 players (24%); 29 players (25%) sustained bilateral HGI. Discussion The most important finding of the present study was that hip and groin injury was the most prevalent non-time-loss Severity of hip and groin injury injury in female amateur football players (17%). There was a high within-season prevalence of total injury (93%) and Players with HGI in the previous season had lower HAGOS scores in the preseason than players without HGI in the hip and groin injury (40%) and a high preseason prevalence of HGI (27%). Non-time-loss injuries were more prevalent previous season (p < 0.001). Players with major HGI in the 1 3 Knee Surgery, Sports Traumatology, Arthroscopy Table 5 HAGOS subscale scores for players with hip and groin injury in the 2014–2015 season HGI subgroups Pain Symptoms ADL SR PA QOL No HGI (n = 262) 100.0 (97.5–100.0) 92.9 (85.7–100.0) 100.0 (100.0– 100.0 (100.0– 100.0 (75.0– 100.0 (100.0–100.0) 100.0) 100.0) 100.0) Difference HGI– < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 No HGI HGI (n = 172) 92.5 (80.0–97.5) 78.6 (71.4–89.3) 95.0 (80.0–100.0) 89.1 (74.3–100.0) 87.5 (75.0–100.0) 90.0 (75.0–100.0) Difference no < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 HGI–minor HGI Minor HGI 95.0 (85.0–100.0) 82.1 (75.0–92.9) 100.0 (85.0–100.0) 93.8 (78.1–100.0) 87.5 (75.0–100.0) 95.0 (85.0–100.0) (n = 103) Difference minor– 0.034 0.062 0.285 0.306 0.320 0.008 moderate HGI Moderate HGI 90.0 (77.5–95.0) 75.0 (67.9–89.3) 95.0 (80.0–100.0) 87.5 (71.9–100.0) 87.5 (75.0–100.0) 77.5 (70.0–95.0) (n = 30) Difference moder - 0.078 0.283 0.170 0.046 0.012 0.016 ate–major Major HGI 77.5 (70.0–95.0) 75.0 (60.7–82.1) 90.0 (70.0–100.0) 75.0 (56.3–93.8) 75.0 (50.0–87.5) 70.0 (55.0–85.0) (n = 39) Difference minor– < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 major HGI HAGOS scores (median, IQR) obtained at the current preseason for all players, for players with HGI, with no HGI and for the duration groups minor (1–7 days), moderate (8–28 days), and major (> 28 days) HGI, all in the previous season. p values are presented for differences between two subgroups HAGOS hip and groin outcome score, HGI hip and groin injury, ADL activities of daily living, SR sport and recreational activities, PA participa- tion in physical activity: QOL quality of life, IQR inter quartile range, n number Fig. 2 Player flow from the previous season to the current preseason for players with hip and groin injury per duration category, and for those with no HGI in the previous season 1 3 Knee Surgery, Sports Traumatology, Arthroscopy than time-loss injuries. More than half of all hip and groin Duration and severity of hip and groin injury injuries in the previous season were recurrent or chronic injuries in the following preseason. The longer the duration Half of the players (52%) with HGI in the previous sea- of HGI in the previous season, the higher the chance of car- son were still injured or re-injured after the off-season. This rying over hip and groin problems into the following season. proportion was found to be one-third in male sub-elite play- ers [24, 26]. In the new preseason, a quarter of all players (27%) reported hip and groin problems, with a full season Presence of total injury still to come. This was also reported by male players, with a preseason prevalence of 36% [26]. As longstanding HGI Non-time-loss injury rates (63%) were almost double that related to more severe hip and groin problems (low HAGOS of time-loss injury rates (37%), which is in line with the scores), not only a previous time-loss injury [34] but also the previous studies in female collegiate sports [4, 17]. A TLI duration of hip and groin problems may relate to the risk of prevalence of 37% agrees with the previous studies in female recurrence, chronicity, and time-loss [10, 26]. football that used only a TLI definition (38–48%) [6 , 11, 14, Players with longstanding HGI (> 1 month) had identical 20]. Of all injuries, 88% were located in the lower body, HAGOS scores on the subscales of pain and participation which was also found in the previous studies (82% [11], as those from a study in male players (> 1.5 months) [26]. 87% [12], and 89% [20]). The hip/groin was the most fre- quently affected injury location (17%) for NTLI. TLI most Clinical implications often affected the ankle (22%) and knee (18%), which agrees with the previous reports in time-loss injury locations in Our study shows that there is a significant injury burden in elite female football [6, 11, 14, 20]. Non-time-loss injuries female amateur football. Prevention of injuries has a high accounted for 63% and time-loss accounted for 37% of all priority within the sport. We also found that how injuries injuries. Therefore, an average team of 15 players had 49 are measured and defined affects the incidence rates, with injuries (31 NTLI and 18 TLI) in the 2014–2015 season. TLI being only the tip of the injury iceberg. With regard to HGI, this study demonstrates the importance of a measure- ment tool to quantify not only time-loss yet also the severity Presence of hip and groin injury of hip and groin problems for trainers, players, and medical staff. The results of this study showed that nearly half of the Nearly half of the female amateur players (40%) sustained players with short-term HGI (< 1 week) sustained recur- HGI in the previous season, which is similar to injury rates rent hip and groin injury during the following preseason. found in a Norwegian survey study in elite female players To identify players with increased risk for longstanding and (45%) [9]. A Swedish survey study showed lower rates (28%) severe hip and groin-related problems, regular assessment in sub-elite female players [27]. Seasonal incidences of 49% of hip and groin symptoms and sports performance should [26] and 55% [13] were found in male players. Female and be performed [10, 26]. As the HAGOS has been developed male HGI incidence may be much more comparable than and validated to measure symptoms and sports performance previously reported [30]. In this study, an average team had in detail, it is a useful tool for measuring severity of HGI seven hip and groin injuries (five NTL-HGI and two TL- instead of dichotomous reporting on time-loss injury [26]. HGI) in one season, resulting in 53 days of ongoing hip and This study used players from all KNVB districts across groin problems and 21 days of play lost. the whole country, instead of regional allocation that can In the previous season, 36% of all players continued play- possibly lead to allocation bias. To avoid underestimation ing despite hip and groin problems (NTL-HGI), whereas of the actual injury burden of (overuse) injuries, both NTLI 11% had stopped playing for at least 1 day due to these prob- and TLI were assessed [1]. Players self-reported their inju- lems (TL-HGI). Similar findings (36 vs. 9%) were recently ries instead of medical staff, as many amateur clubs have no shown in elite Norwegian female players [9]. The previous structured medical care. To increase the precision of report- studies on female time-loss groin injury reported similar ing and target recall, we chose to use figures to specify ana- findings (2–11%) [5 , 9, 14, 22], and a recent review reported tomical regions. that TL-HGI rates in males were twice as high as in females We acknowledge a number of limitations. As this was a [30]. All these studies had more or less comparable exposure surveillance study without assessment by a medical profes- rates (148 in this study vs. 198 [14], 212 [5], and 213 [22] sional, the classification of groin pain following the clinical hours/player), yet a study with a higher exposure rate (393 h/ entity approach, as recommended by the DOHA agreement player) also had a much higher injury rate (46%) [8]. It may [32], could not be performed. A correct diagnosis is manda- be that injury rates depend more on exposure than on gender tory for effective management and prognosis. 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Accessed 22 Feb Affiliations 1,2,3,4,5 6,7 8 9 10 2,3,11 Rob Langhout  · Adam Weir  · Wendy Litjes  · Maarten Gozeling  · Janine H. Stubbe  · Gino Kerkhoffs  · 2,3,5,12 Igor Tak 1 7 Department for Manual Therapy and Sports Rehabilitation, Department of Orthopaedics, Erasmus MC Center for Groin Physiotherapy Dukenburg Nijmegen, Aldenhof 7003, Injuries, Erasmus MC University Medical Centre, Rotterdam, 6537 DZ Nijmegen, The Netherlands The Netherlands 2 8 Amsterdam Collaboration for Health and Safety in Sports Department of Sports Rehabilitation, Physiotherapy Wijchen, (ACHSS), AMC-VUmc IOC Research Center, Amsterdam, Wijchen, The Netherlands The Netherlands Department of Physiotherapy, PSV Eindhoven, Eindhoven, Academic Center for Evidence-Based Sports Medicine The Netherlands (ACES), Amsterdam, The Netherlands Codarts Rotterdam, University of the Arts, Rotterdam, Advanced Studies Manual Therapy, SOMT University, The Netherlands Amersfoort, The Netherlands Department of Orthopaedic Surgery, Academic Medical Dutch Center for Allied Health Care (NPi), Amersfoort, Center, University of Amsterdam, Amsterdam Movement The Netherlands Sciences, Amsterdam, The Netherlands 6 12 Sports Groin Pain Centre, Aspetar Orthopaedic and Sports Department for Manual Therapy and Sports Rehabilitation, Medicine Hospital, Doha, Qatar Physiotherapy Utrecht Oost, Utrecht, The Netherlands 1 3 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Knee Surgery, Sports Traumatology, Arthroscopy Springer Journals

Hip and groin injury is the most common non-time-loss injury in female amateur football

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Medicine & Public Health; Orthopedics
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0942-2056
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10.1007/s00167-018-4996-1
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Abstract

Purpose Hip and groin injuries in football are problematic due to their high incidence and risk of chronicity and recurrence. The use of only time-loss injury definitions may underestimate the burden of hip and groin injuries. Little is known about hip and groin injury epidemiology in female football. The first aim of this study was to examine the within-season (2014–2015) prevalence of total injury with and without time-loss in female amateur football players. The second aim was to study the within-season and preseason (2015–2016) prevalence of hip/groin injuries with and without time-loss. The third aim was to study the association between the duration of hip and groin injury in the 2014–2015 season and the severity of hip/groin problems during the 2015–2016 preseason. Methods During the preseason, 434 Dutch female amateur football players completed an online questionnaire based on the previous season and current preseason. The hip and groin outcome score (HAGOS) was used to assess the severity of hip and groin injuries. Results The hip/groin (17%), knee (14%), and ankle (12%) were the most frequent non-time-loss injury locations. The ankle (22%), knee (18%), hamstring (11%), thigh (10%), and hip/groin (9%) were the most common time-loss injury locations. The previous season prevalence of total injury was 93%, of which non-time-loss injury was 63% and time-loss injury was 37%. The prevalence of hip/groin injury was 40%, non-time-loss hip/groin injury was 36% and time-loss hip/groin injury was 11%. The preseason prevalence of hip/groin injury was 27%, non-time-loss hip/groin injury was 25%, and time-loss hip/ groin injury was 4%. Players with longstanding hip/groin injury (> 28 days) in the previous season had lower HAGOS scores at the next preseason than players with short-term (1–7 days) or no hip/groin injury (p < 0.001). From all players with hip/ groin injury from the previous season, 52% also sustained hip/groin injury in the following preseason, of which 73% were recurrent and 27% were chronic hip/groin injuries. Conclusion Injury risk, and especially non-time-loss hip and groin injury risk, is high in female amateur football. Three- quarters of the players with longstanding hip and groin injuries in the previous season have residual problems at the start of the following season. Level of evidence II. Keywords Female football (soccer) · Female athlete · Groin pain · Hip and groin injury Introduction The number of female football players in Europe is growing rapidly, and female participation rates in the US almost equal those of males [28]. Dutch female football has increased Electronic supplementary material The online version of this rapidly, with 23% more players over the past 5 years and article (https ://doi.org/10.1007/s0016 7-018-4996-1) contains supplementary material, which is available to authorized users. 153,001 registered players in the 2016–2017 season. It is now the largest female team sport in Holland [28]. * Rob Langhout Despite its popularity and growth, injury studies in langhout.rob@gmail.com female football lag far behind those in male football [21]. In Extended author information available on the last page of the article Vol.:(0123456789) 1 3 Knee Surgery, Sports Traumatology, Arthroscopy addition, most injury or risk factor studies use only time-loss Participants injury (TLI) definitions [7 , 30]. The within-season preva- lence of TLI in elite female football ranges between 38 and All participants were female amateur players in the Dutch 48% [4, 6, 10, 11, 14, 15, 20]. Non-time-loss injury (NTLI) women’s football league, as registered by the Royal Dutch has been less studied in football [30]. The little available Football Association (KNVB). To obtain a large sample data suggest, as expected, that NTLI is more common than size, 43 teams (645 players), representing all amateur play- TLI [9, 17]. ing levels (top class, sub-top class, 1st–6th class) from all Studies reporting specifically on hip and groin injury KNVB districts were selected and invited by e-mail to par- (HGI) are hard to compare, as they use different injury ter - ticipate in this general injury survey. Every player received minologies and definitions [ 2, 32]. A study in elite female information by e-mail about the study and instructions for football players found that injury rates were four times completing the questionnaire (Supplementary Appendix). higher (36 vs. 9%) for non-time-loss HGI (NTL-HGI) than Players were included if they were female, were between for time-loss HGI (TL-HGI) [9]. A recent systematic review the ages of 18 and 40, and had played amateur football showed that, in elite female studies, prevalence rates of during the previous season, regardless of being injured TL-HGI ranged from 2 to 11% [30]. The use of TL-HGI or not. Professional players and those from the veteran’s definitions probably underestimates the true burden of HGI leagues were excluded. The parameters of age, height, [7, 26]. HGI is common in (sub-) elite male football and is weight, weekly average exposure (training and matches), known for its high incidence, chronicity, and risk of recur- leg dominance (defined as the preferred kicking leg), and rence [19, 26, 34]. Injury risk and prevention has yet not playing levels were self-reported. been studied in female amateur football players [30]. Patient-reported outcome measures (PROs) are the gold standard for assessing the perceived health status of spe- Injury registration cific populations and injuries [16]. The hip and groin out- come score (HAGOS) is developed for young and active Time-loss injury (TLI) was defined as ‘Any physical com- individuals, measures the severity of hip- and groin-related plaint sustained by a player as a result of a football match problems, and is validated in several languages, including or training, resulting in a player being unable to fully take Dutch [23, 25, 27]. part in future football training or match play’ [7]. Non- Limited literature exists on female football players and time-loss injury (NTLI) was defined as a situation where especially on the hip/groin injuries. Most literature on this players experienced ‘Any physical complaint as a result topic studied professional players, although the amount of of a football match or training, but without time-loss’ [7]. amateur football players is the majority of the people that The same definitions applied for hip and groin injury, visit the sports clinic. Therefore, the first aim of this study referring to NTL-HGI and TL-HGI. The presence of injury was to examine the within-season (2014–2015) prevalence was scored by dichotomous answer options (yes/no). of total injury burden (NTLI and TLI) in female amateur When present, the duration (days) of both NTL-HGI football. The second aim was to study the within-season and and TL-HGI was noted and classified as minor (1–7 days), preseason (2015–2016) prevalence of hip and groin injury moderate (8–28 days), or major (> 28 days), according to (NTL-HGI and TL-HGI). The third aim was to examine the the international classification for football injuries [7 ]. In association between the duration of HGI in the 2014–2015 addition, the manner of onset (maximal kicking, sprinting/ season and the severity of hip/groin problems during the running, cutting/pivoting, and other) of HGI was regis- 2015–2016 preseason. tered for the 2014–2015 season. An online registration system was used (Google Forms). Materials and methods Injury region In this cross-sectional survey study, female amateur foot- A body chart was used to illustrate all locations of NTLI ball players completed an online questionnaire during the and TLI based on the Dutch Injury Information System 2015–2016 preseason. The ‘Strengthening the Reporting of framework and Orchard Sports Injury Classification Sys- Observational Studies in Epidemiology’ (STROBE state- tem [18]. For this study, the hip/groin was referred to as ment) was used to report the findings of this study [29]. ‘the region between the front of the hip and the inner front By clicking the “I participate” link in the electronic ques- of the thigh’ [18]. A chart of the hip and groin region was tionnaire, the participants gave their consent that their used to address the location of HGI in this region. anonymized data could be used for research purposes. 1 3 Knee Surgery, Sports Traumatology, Arthroscopy Hip and groin outcome score (HAGOS) Statistical analysis The HAGOS was used to assess the severity of hip- and The data were tested for normality using the Kolmogo- groin-related problems for all players on six subscales: pain rov–Smirnov test. Normally distributed data are presented (P), symptoms (S), activities of daily living (ADL), sport as a mean and standard deviation (SD). Non-normally dis- and recreation (SR), participation in physical activities (PA), tributed data are presented as a median and interquartile and quality of life (QOL) [27]. Subscale scores range from 0 range (IQR 25–75%). The presence and locations of NTLI to 100, where 0 indicates severe hip and groin symptoms and and TLI are presented as absolute (counts) and relative (per- problems, and 100 indicates no symptoms or problems [27]. centage of total). To avoid overestimation, HGI was defined HAGOS is available in the Dutch language and is found to as the total number of players with NTL-HGI and TL-HGI be reliable (ICCs between 0.83 and 0.87), internally consist- minus the number of players with both injuries. The duration ent (Cronbach’s α between 0.81 and 0.92), valid in young (days) of NTL-HGI and TL-HGI was analysed by frequen- athletes (including football players), and comparable to the cies and percentage of the total number of players. The aver- original Danish version [23]. The mean ± SD test–retest dif- age number of players for an average squad was calculated ferences for the six subscales were 0.5 ± 10.9 (P), 1.7 ± 10.4 to examine the number of injuries per squad per season. (S), 0.4 ± 14.2 (ADL), 2.8 ± 15.8 (SR), 2.3 ± 18.9 (PA), and To calculate duration (days) of NTL-HGI and TL-HGI per 2.5 ± 11.5 (QOL). squad, an arbitrary duration of 3 days was chosen for minor HGI, 18 days for moderate HGI, and 28 days for major HGI, Survey period to prevent overestimation. Match and training exposure were determined (hours) Participants were asked to complete the injury question- and 1 match represented 1.5 h. A Mann–Whitney U test naire (including HAGOS) during an 8-week period in the was used to examine differences between HAGOS scores preseason of 2015–2016 (August, September, and October for HGI, no HGI, and HGI duration groups. Incorrect or 2015). NTLI and TLI were retrospectively assessed per body missing data were reported and corrected by the means of location for the previous season (1 August 2014–15 June the variables and frequencies. The level of significance was 2015). NTLI-HGI and TL-HGI were assessed for the previ- set at α < 0.05. The data were analysed using SPSS 23 (IBM, ous season and for the current preseason. History of HGI Armonk, USA). was assessed for the period prior to the 2014–2015 season. The HAGOS scores concerned the player’s health status for the week prior to completing the questionnaire (see the Sup- Results plementary Appendix for the survey and HAGOS at http:// www.koos.nu). Of the 43 teams invited, 8 teams (120 players) declined the Bias invitation and 35 teams participated in this study (response rate 81%). This resulted in 525 female players, from which To minimize recall bias, dichotomous answer options, defi- 91 (17%) failed to meet the inclusion criteria of being at least 18 years of age (n = 89) or participating in the included nitions of the terms used, and assisting figures that specified anatomical regions were employed [16]. Adequate reliability playing levels (n = 2 veterans league). Data from 434 players were used for the analysis (Fig. 1). between retrospective and prospective dichotomous registra- tion of self-reported injuries has been previously observed During the previous season, the 434 players had a total exposure time of 64,034  h (50,720 training and 13,314 [3]. match hours). On average, each player spent 148 ± 58  h playing football (117 ± 54 training and 31 ± 12 match hours) Approval during the 40-week competitive season. An average team consisted of 14.7 ± 0.7 players. Player characteristics are This study complied with the requirements of the declaration of Helsinki [35]. The Dutch Central Committee on Research shown in Table 1. Involving Human Subjects (CCMO) states that no medical ethical approval was necessary for this questionnaire study. Total injury during the previous season Participants were neither physically examined nor treated by any means. As such no burden existed nor were they denied For the previous season, 404 players (93%) reported 1439 any treatment. This is stated in the Dutch Medical Research Involving Human Subjects Act (WMO; http://wette n.overh injuries, of which 904 (63%) were NTLI and 535 (37%) were TLI. Most injured players had one NTLI (n = 136, eid.nl/ BWBR0009408). 1 3 Knee Surgery, Sports Traumatology, Arthroscopy Fig. 1 Flowchart showing player inclusion and exclusion 31%) or one TLI (n = 175, 40%) (Table  2). An average Table 1 Player characteristics (n = 434) squad of 15 players can expect 49 injuries (31 NTLI and 18 TLI) per season. Age (years) 24.2 (5.1; 18–52) The most affected NTLI locations were the hip/groin Height (cm) 170.7 (6.0; 155–190) (17%), knee (14%) and ankle (12%). The most affected TLI Weight (kg) 66.4 (8.7; 46–110) locations were the ankle (22%), knee (18%), hamstring ) 22.6 (2.7; 17.1–40.0) Body mass index (kg/m (11%), thigh (10%), and hip/groin (9%) (Table 3). Of all Match exposure (total matches per season) 20.9 (8.7; 0–60) 1439 injuries, 1261 (88%) were located in the lower body Training exposure (hours per week) 3.0 (1.4; 0–12) (including lumbar spine and pelvis). Playing level, n (%)  Top class 23 (5)  Sub-top class 48 (11) Hip and groin injury during the previous season  First class 60 (14)  Second class 51 (112) For the previous season, 172 players (40%) reported 200  Third class 35 (8) HGI. Of these 172 players, 28 players (6%) had both  Fourth class 95 (22) NTL-HGI and TL-HGI, 126 players (30%) sustained only  Fifth class 89 (21) NTL-HGI, and 18 players (4%) sustained only TL-HGI.  Sixth class 33 (8) The prevalence of NTL-HGI was 36% (154 injuries) and Leg dominance, n (%) prevalence of TL-HGI was 11% (46 injuries) (Table 4). A  Left 45 (10) history of HGI prior to the 2014–2015 season was reported  Right 389 (90) in 166 players (38%). Of those, 101 players (23%) also HAGOS subscales sustained HGI in the 2014–2015 season.  Pain (P) 100.0 (90.0–100.0) The dominant leg was affected in 100 players (58%),  Symptoms (S) 89.3 (78.6–100.0) and the non-dominant leg was affected in 33 players  Activities of daily living (ADL) 100.0 (95.0–100.0) (19%); 39 players (23%) sustained bilateral HGI. The onset  Sports and recreation (SR) 100.0 (87.5–100.0) for HGI was maximal kicking (24%), sprinting/running  Participation in physical activity (PA) 100.0 (75.0–100.0) (21%), pivoting/cutting (11%), and others (44%). An aver-  Quality of life (QOL) 100.0 (85.0–100.0) age amateur squad of 15 players can expect 5 NTL-HGIs Player characteristic presented as the mean (SD, range) or median and 2 TL-HGIs per season, resulting in 53 days of ongoing (IQR 25–75). Exposure is presented for the previous season (2014– hip and groin problems and 21 days of play lost. 2015) y years, cm centimetre, kg kilogram, kg/m kilogram/square metre, IQR interquartile range, n number 1 3 Knee Surgery, Sports Traumatology, Arthroscopy Table 2 Injury frequency (NTLI and TLI) in the previous season, presented per player (n, %) Players, NTLI n (%) 56 (13) 136 (31) 109 (25) 67 (15) 27 (6) 13 (3) 16 (4) 5 (1) 2 (1) 1 (0.2) 2 (0.8) 434 (100) Injury numbers, n 0 1 2 3 4 5 6 7 8 9 10 Total Players, TLI, n (%) 109 (25) 175 (40) 103 (24) 36 (8) 10 (2) – 1 (1) – – – – 434 (100) NTLI non-time-loss injury, TLI time-loss injury, n number Table 3 Injury location and ranking Table 4 Prevalence of hip and groin injury Non-time-loss Injury (NTLI) Time-loss Injury (TLI) Previous Season Preseason Body location Rank n (%) Body location Rank n (%) Players with HGI 172 (40) 117 (27) Players with NTL-HGI 154 (36) 109 (25) Hip/Groin 1 154 (17) Ankle 1 118 (22)  Duration Knee 2 123 (14) Knee 2 94 (18)   Minor (1–7 days) 98 (22) 71 (16) Ankle 3 110 (12) Hamstring 3 57 (11)   Moderate (8–28 days) 28 (7) 28 (7) Lumbar spine 4 92 (10) Thigh 4 52 (10)   Major (> 28 days) 28 (7) 10 (2) Thigh 5 83 (9) Hip/groin 5 46 (9) Players with TL-HGI 46 (11) 23 (5) Hamstring 6 69 (8) Lumbar spine 6 40 (8)  Duration Calf 7 59 (7) Calf 7 33 (6)   Minor (1–7 days) 22 (5) 14 (3) Foot 8 43 (5) Foot 8 24 (4)   Moderate (8–28 days) 11 (2) 2 (1) Shoulder 9 39 (5) Head 9 14 (2)   Major (> 28 days) 13 (3) 7 (2) Neck 10 30 (3) Lower leg 10 13 (2) (front) Self-reported prevalence of HGI (both non-time-loss and time-loss) Lower leg 11 29 (3) Wrist/hand 11 12 (2) in the previous season (2014–2015) and preseason of 2015–2016 (front) (n = 434) is also reported for all duration groups. Data are presented Wrist/hand 12 22 (2) Shoulder 12 10 (2) as numbers (n) and rates (%) Head 13 20 (2) Pelvis 13 9 (1) HGI hip and groin injury, NTL-HGI non-time-loss hip and groin injury, TL-HGI time-loss hip and groin injury Pelvis 14 13 (1) Trunk 14 6 (1) Trunk 15 8 (1) Neck 15 4 (1) Elbow 16 6 (0.6) Face 16 2 (0.8) previous season had lower HAGOS scores in the preseason Face 17 4 (0.4) Elbow 17 1 (0.2) than those with minor HGI (p < 0.001) (Table 5). Total 904 (100) 535 (100) Duration of hip and groin injury Body location and ranking of non-time-loss (NTLI) and time-loss injuries (TLI) for all players (n = 434) in the previous season (n, %) From the 172 players with HGI in the previous season, 82 (48%) had recovered and 90 (52%) sustained HGI in the following preseason. Of these, 66 (73%) were recurrent and Hip and groin injury during the preseason 24 (27%) were chronic HGI. There were 50 recurrent HGI (47%) from the minor HGI group in the previous season and During the preseason, 117 players (27%) reported 132 HGIs. Of these 117 players, 15 (3%) had both NTL-HGI and TL- 16 (52%) from those with moderate HGI. The 24 chronic HGIs originated from the major HGI group (71%) in the HGI, 94 players (22%) sustained only NTL-HGI, and 8 play- ers (2%) sustained only TL-HGI. The prevalence of NTL- previous season. Of the 117 HGIs in the preseason, 27 (23%) were new HGIs (Fig. 2; Table 4). HGI was 25% (109 injuries) and prevalence of TL-HGI was 5% (23 injuries) (Table 4). The dominant leg was affected in 60 players (51%), and the non-dominant leg was affected in 28 players (24%); 29 players (25%) sustained bilateral HGI. Discussion The most important finding of the present study was that hip and groin injury was the most prevalent non-time-loss Severity of hip and groin injury injury in female amateur football players (17%). There was a high within-season prevalence of total injury (93%) and Players with HGI in the previous season had lower HAGOS scores in the preseason than players without HGI in the hip and groin injury (40%) and a high preseason prevalence of HGI (27%). Non-time-loss injuries were more prevalent previous season (p < 0.001). Players with major HGI in the 1 3 Knee Surgery, Sports Traumatology, Arthroscopy Table 5 HAGOS subscale scores for players with hip and groin injury in the 2014–2015 season HGI subgroups Pain Symptoms ADL SR PA QOL No HGI (n = 262) 100.0 (97.5–100.0) 92.9 (85.7–100.0) 100.0 (100.0– 100.0 (100.0– 100.0 (75.0– 100.0 (100.0–100.0) 100.0) 100.0) 100.0) Difference HGI– < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 No HGI HGI (n = 172) 92.5 (80.0–97.5) 78.6 (71.4–89.3) 95.0 (80.0–100.0) 89.1 (74.3–100.0) 87.5 (75.0–100.0) 90.0 (75.0–100.0) Difference no < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 HGI–minor HGI Minor HGI 95.0 (85.0–100.0) 82.1 (75.0–92.9) 100.0 (85.0–100.0) 93.8 (78.1–100.0) 87.5 (75.0–100.0) 95.0 (85.0–100.0) (n = 103) Difference minor– 0.034 0.062 0.285 0.306 0.320 0.008 moderate HGI Moderate HGI 90.0 (77.5–95.0) 75.0 (67.9–89.3) 95.0 (80.0–100.0) 87.5 (71.9–100.0) 87.5 (75.0–100.0) 77.5 (70.0–95.0) (n = 30) Difference moder - 0.078 0.283 0.170 0.046 0.012 0.016 ate–major Major HGI 77.5 (70.0–95.0) 75.0 (60.7–82.1) 90.0 (70.0–100.0) 75.0 (56.3–93.8) 75.0 (50.0–87.5) 70.0 (55.0–85.0) (n = 39) Difference minor– < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 major HGI HAGOS scores (median, IQR) obtained at the current preseason for all players, for players with HGI, with no HGI and for the duration groups minor (1–7 days), moderate (8–28 days), and major (> 28 days) HGI, all in the previous season. p values are presented for differences between two subgroups HAGOS hip and groin outcome score, HGI hip and groin injury, ADL activities of daily living, SR sport and recreational activities, PA participa- tion in physical activity: QOL quality of life, IQR inter quartile range, n number Fig. 2 Player flow from the previous season to the current preseason for players with hip and groin injury per duration category, and for those with no HGI in the previous season 1 3 Knee Surgery, Sports Traumatology, Arthroscopy than time-loss injuries. More than half of all hip and groin Duration and severity of hip and groin injury injuries in the previous season were recurrent or chronic injuries in the following preseason. The longer the duration Half of the players (52%) with HGI in the previous sea- of HGI in the previous season, the higher the chance of car- son were still injured or re-injured after the off-season. This rying over hip and groin problems into the following season. proportion was found to be one-third in male sub-elite play- ers [24, 26]. In the new preseason, a quarter of all players (27%) reported hip and groin problems, with a full season Presence of total injury still to come. This was also reported by male players, with a preseason prevalence of 36% [26]. As longstanding HGI Non-time-loss injury rates (63%) were almost double that related to more severe hip and groin problems (low HAGOS of time-loss injury rates (37%), which is in line with the scores), not only a previous time-loss injury [34] but also the previous studies in female collegiate sports [4, 17]. A TLI duration of hip and groin problems may relate to the risk of prevalence of 37% agrees with the previous studies in female recurrence, chronicity, and time-loss [10, 26]. football that used only a TLI definition (38–48%) [6 , 11, 14, Players with longstanding HGI (> 1 month) had identical 20]. Of all injuries, 88% were located in the lower body, HAGOS scores on the subscales of pain and participation which was also found in the previous studies (82% [11], as those from a study in male players (> 1.5 months) [26]. 87% [12], and 89% [20]). The hip/groin was the most fre- quently affected injury location (17%) for NTLI. TLI most Clinical implications often affected the ankle (22%) and knee (18%), which agrees with the previous reports in time-loss injury locations in Our study shows that there is a significant injury burden in elite female football [6, 11, 14, 20]. Non-time-loss injuries female amateur football. Prevention of injuries has a high accounted for 63% and time-loss accounted for 37% of all priority within the sport. We also found that how injuries injuries. Therefore, an average team of 15 players had 49 are measured and defined affects the incidence rates, with injuries (31 NTLI and 18 TLI) in the 2014–2015 season. TLI being only the tip of the injury iceberg. With regard to HGI, this study demonstrates the importance of a measure- ment tool to quantify not only time-loss yet also the severity Presence of hip and groin injury of hip and groin problems for trainers, players, and medical staff. The results of this study showed that nearly half of the Nearly half of the female amateur players (40%) sustained players with short-term HGI (< 1 week) sustained recur- HGI in the previous season, which is similar to injury rates rent hip and groin injury during the following preseason. found in a Norwegian survey study in elite female players To identify players with increased risk for longstanding and (45%) [9]. A Swedish survey study showed lower rates (28%) severe hip and groin-related problems, regular assessment in sub-elite female players [27]. Seasonal incidences of 49% of hip and groin symptoms and sports performance should [26] and 55% [13] were found in male players. Female and be performed [10, 26]. As the HAGOS has been developed male HGI incidence may be much more comparable than and validated to measure symptoms and sports performance previously reported [30]. In this study, an average team had in detail, it is a useful tool for measuring severity of HGI seven hip and groin injuries (five NTL-HGI and two TL- instead of dichotomous reporting on time-loss injury [26]. HGI) in one season, resulting in 53 days of ongoing hip and This study used players from all KNVB districts across groin problems and 21 days of play lost. the whole country, instead of regional allocation that can In the previous season, 36% of all players continued play- possibly lead to allocation bias. To avoid underestimation ing despite hip and groin problems (NTL-HGI), whereas of the actual injury burden of (overuse) injuries, both NTLI 11% had stopped playing for at least 1 day due to these prob- and TLI were assessed [1]. Players self-reported their inju- lems (TL-HGI). Similar findings (36 vs. 9%) were recently ries instead of medical staff, as many amateur clubs have no shown in elite Norwegian female players [9]. The previous structured medical care. To increase the precision of report- studies on female time-loss groin injury reported similar ing and target recall, we chose to use figures to specify ana- findings (2–11%) [5 , 9, 14, 22], and a recent review reported tomical regions. that TL-HGI rates in males were twice as high as in females We acknowledge a number of limitations. As this was a [30]. All these studies had more or less comparable exposure surveillance study without assessment by a medical profes- rates (148 in this study vs. 198 [14], 212 [5], and 213 [22] sional, the classification of groin pain following the clinical hours/player), yet a study with a higher exposure rate (393 h/ entity approach, as recommended by the DOHA agreement player) also had a much higher injury rate (46%) [8]. It may [32], could not be performed. A correct diagnosis is manda- be that injury rates depend more on exposure than on gender tory for effective management and prognosis. 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Accessed 22 Feb Affiliations 1,2,3,4,5 6,7 8 9 10 2,3,11 Rob Langhout  · Adam Weir  · Wendy Litjes  · Maarten Gozeling  · Janine H. Stubbe  · Gino Kerkhoffs  · 2,3,5,12 Igor Tak 1 7 Department for Manual Therapy and Sports Rehabilitation, Department of Orthopaedics, Erasmus MC Center for Groin Physiotherapy Dukenburg Nijmegen, Aldenhof 7003, Injuries, Erasmus MC University Medical Centre, Rotterdam, 6537 DZ Nijmegen, The Netherlands The Netherlands 2 8 Amsterdam Collaboration for Health and Safety in Sports Department of Sports Rehabilitation, Physiotherapy Wijchen, (ACHSS), AMC-VUmc IOC Research Center, Amsterdam, Wijchen, The Netherlands The Netherlands Department of Physiotherapy, PSV Eindhoven, Eindhoven, Academic Center for Evidence-Based Sports Medicine The Netherlands (ACES), Amsterdam, The Netherlands Codarts Rotterdam, University of the Arts, Rotterdam, Advanced Studies Manual Therapy, SOMT University, The Netherlands Amersfoort, The Netherlands Department of Orthopaedic Surgery, Academic Medical Dutch Center for Allied Health Care (NPi), Amersfoort, Center, University of Amsterdam, Amsterdam Movement The Netherlands Sciences, Amsterdam, The Netherlands 6 12 Sports Groin Pain Centre, Aspetar Orthopaedic and Sports Department for Manual Therapy and Sports Rehabilitation, Medicine Hospital, Doha, Qatar Physiotherapy Utrecht Oost, Utrecht, The Netherlands 1 3

Journal

Knee Surgery, Sports Traumatology, ArthroscopySpringer Journals

Published: Jun 2, 2018

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