Evaluation of Injuries in Professional Turkish Football Players

Aim: It is important to evaluate the injury patterns and anatomic localization of the injuries according to the playing position for the prevention of injuries and reduction of injury cost in football which is the most popular in the world. The purpose of this study was to evaluate the injury pattern and anatomical localization of injuries. Method: The injury pattern was evaluated with a questionnaire with the participation of 510 football players playing for the teams attending the First and Second Professional Turkish Leagues. Result: For different playing positions abrasions were 64.55-85.42%, muscular strains were 52.06-64.58%, joint sprains were 19.58-49.37% and fractures were 2.58-6.39% present. Regardless from the playing position lower extremity injuries were the most common injuries detected (60.5%). Conclusion: It was suggested that these data would be helpful for the reduction of injury risks and the costs besides with proper onsite precautions.


INTRODUCTION
Football is one of the most popular sports branches in the world (1,5,10,14).Approximately, 200 million individuals play football, 200.000 of them play professionally (10).Especially when professional football is considered this popularity creates a big financial effect (17).
It is known that the risk of the injury of footballers is very high (2,9,11).It is stated that the risk of injury in professional football is approximately thousand times higher than industrial occupations which are accepted as being high risky (1).It is estimated that every elite male footballer is exposed to injury which limits the performance at least one time throughout a year (10).The effects of injuries and previous injuries can affect the performance of the player (2).Because of the injuries, there are some economic casualties who are listed as follows: Increase of the health expenses, decrease in the club incomes because of the absence of first preference players, decrease of price in certificate of good service of wounded players, decrease in the club success (17).Taking into account these factors it is evident that the type of the injury, anatomical localization of it, playing position of the footballer is important not only to prevent the injuries but also for treatment.
The aim of this study was to determine the injured part of the body, the type of the footballers' injury and to evaluate the relationship between the type of the injury and the playing positions.

MATERIALS AND METHODS
In 2005-2006 Season, totally 510 professional male soccer players who consisted of 48 goalkeepers, 194 defender players, 189 mid-field players and 79 forward players who played in 1st and 2nd Turkish Professional Soccer Leagues, agreed to participate in this study.This investigation included injuries of players in one season.Before the study, informed consent in accordance with the club administrators and cooperation were established with the sanitary staffs of each team.The players were informed about these investigation by written documents and verbally.Recorded registration forms and reports of formal competitions and trainings in last season were observed.According to available reports; age, sex, player positions, time of injuries, type of injuries, and grade of injuries and anatomical region of injuries were questioned.Another questionnaire was arranged for representing injuries of attendance players in respect of demographic information and player positions.This questionnaire was applied to players by club doctors in the last week of season.SPSS for Windows was used for analysis of investigation.Answers of each question in questionnaire were calculated with respect to percent amount of injury types and anatomical region and finally all percent values were discussed according to player position.

DISCUSSION
The aim of this investigation was questioned injuries of players during the formal competitions and trainings in last one season, were time of injuries, type injuries, anatomical regions and grade of injuries according to player positions.
In the study of Cromwell et al. ( 4) which was conducted on 107 Welsh professional players 77% of the injuries were found to be located in the lower extremity.It was detected that most of these injuries were located in ankle region, mainly soft tissue type.In the study of Hawkins et al. (6), in which the injury localization was evaluated 87% of them were located in the lower ex- Injuries in professional football players tremities.Woods et al. (17) found that 77% of the injuries were related with lower extremities.In the study of Adamczyk (1), it was stated that the most effected part of the body was lower extremities regarding with sports injuries.In our study, when the whole study group was considered 60, 5% of the injuries were found to be in lower extremity (Table 4).When the playing positions were considered 59, 79%-61, 87% of the injuries was detected in lower extremities (Table 3).The results obtained in our study were found to be lower than those of Cromwell et al. ( 4), Hawkins et al. (6) and, Woods et al. (17).In our study although the percentage of lower extremity injuries were found to be lower than the results of Adamczyk (1), the lower extremity being the most af-fected part of the body was in accordance.Cromwell et al. (4) found that the most injured part in the lower extremity was ankle.In our study, it was determined that ankle injuries were more frequent with 54, 5-83, 3% in different playing positions (Table 2).These findings support the study of Cromwell et al. (4).In our study it was stated that foot and ankle's injuries were found to be higher in goalkeepers and forwards.

Figure 1. Injury types according to playing positions
In the study of Yoon et al. (15) which was performed on 401 Asian footballers; it was found that 18,5% of the injuries were in knees, 17,3% of them were between knee and ankle, and 14,2% were related with ankles.
The most frequent type of injury was found to be con- tusion whereas sprain was more serious.In our study, regarding different playing positions knee injuries were 39, 18-55, 7% (Table 2).Leg injuries were detected 46, 56-56, 25% (Table 2).These results are higher than those of reported by Yoon et al. (15).In our study, the most frequent injuries detected were skin abrasions and muscular strains.Also it was stated that sprains were less frequent and forwards were the ones who most complained about this kind of injury.The differences detected between the results of Yoon et al. ( 15) may be due to the differences in questionnaires and terminology regarding the injuries.

Tablo 2. Distribution of injuries according to playing positions depending on anatomical localizations
In the study of Cromwell et al. ( 4) it was stated that 33% of soft tissue injuries were in knees, 16% were in tendons.In our study, muscle injuries were found to be 52, 06%-64, 58% (Table 1) and it's higher than the results of Cromwell et al. (4).Similarly, in our study tendon injuries were 35, 45%-43, 75% (Table 1) and were higher than the results stated by Cromwell et al. (4).
In the study of Hawkins et al. (6) in which the injuries reported from 91 professional football clubs during two seasons 6030 injuries were detected.It was stated that 37% of these injuries were muscular strains, 19% were ligamentous sprains, 7% were muscular sprains and 4% were fractures.Skin abrasions were reported to be only 3 times within all the injuries.In our study, skin abrasions were 64, 35-85, 42% depending on the playing position (Table 1) and this result higher than results of Hawkins et al. (6).In our study, muscular strain and tendon strains were also found to be higher than the findings of Hawkins et al. ( 6) (Table 1).Our results regarding fractures were found to be similar with those of Hawkins et al. ( 6) (Table 1).
In the study of Woods et al. (17) in which the preseason injuries in England professional football league were evaluated 23% of 6030 injuries were in thigh, 17% were in knee, 17% were in ankle, 12% were in leg, 6% were in foot and toes, 2% were in hip and 3% were in upper extremity.In our study, the thigh injuries of goal keepers, defenders and forwards were found to be higher than those reported by Woods et al. (17) whereas the injuries of mid-field players were in accordance with the results of Woods et al. (17).When all the playing positions were considered our results were higher than those stated by Woods et al. (17).When the type of the injury was considered Wood et al. (17) reported that 37% of the injuries were muscular strains, 7% were mus- cular contusions, 5% were tendon injuries and 5% were fractures.In our study muscular strains were 52, 06-56, 58% and higher than the results of Woods et al. (17).

Figure 3. Total injuries according to different anatomical localizations
The percentage of tendon injuries and fractures were also found to be higher in our study.The differences between the two studies may originate from different questionnaires used in these studies.
In the study of Chomiak et al. (3) in which 398 football players participated, 686 injuries were reported during one year.16% of these injuries were reported to be serious.30% were joint sprains, 16% were fractures, 15% were muscle strains, and 12% were ligament ruptures.29% of these injuries were in knee.In our study joint sprains were 19.58% and 49.37% regarding different playing positions.Our results were higher than those reported by Chomiak et al. (3).In our study fractures were found to be lower than those reported by Chomiak et al. [3] whereas strains were found to be higher.Injuries regarding knee were also found to be higher regarding different playing positions.
In the study of Hawkins (7) which was performed on 4 professional English football teams, it was stated that among the 391 injuries which had occurred during the matches 37% of them were strains, 21% were sprains, 4% were fractures and 2% were lacerations.23% of these injuries were in thigh, 12% were in leg, 7% were in foot, 6% were in trunk, 3% were in head, 2% were in upper extremity and 3% were in the hip.The percentage of muscle strains detected in our study (Table 1) was found to be higher than the results of Hawkins (7).The percentage of sprains among the goalkeepers and midfielders was similar to those stated by Hawkins (7) whereas it was higher among other playing positions.The percentage of fractures in our study was similar to the results that have been reported by Hawkins (7).On the other hand, the percentage of lacerations was higher than their findings (Table 1).In our study, the lower extremity injury rate and the body injury rate were similar to results of Hawkins (7).However in our study, the percentage of head and neck injuries was higher and the percentage of upper extremity injury was 12 times.
In our study the percentage of sprains that are detected among the goalkeepers, defenders and mid-fielders were similar to the results of Adamczyk (1), however the percentage of sprains among the forwards was higher.Besides, muscular strains detected in our study were much higher.In the study of Adamczyk (1), it was stated that head, vertebral column, trunk injuries were more frequent compared to upper extremity injuries, however the percentage of upper extremity injuries was higher than trunk and head and neck injuries in our study.
It was stated in the literature that more than 75% of the injuries among the footballers were strains, sprains and contusion type injuries.It was also reported that lower extremity injuries constituted 60-85% of the injuries among footballers and knee joint and then ankle joint were being the most affected joints (12).Similarly, in our study the percentage of strain and sprain type injuries were found to be higher (Table 1).As it has also been stated by Rahmana (12), lower extremity injuries were the most frequent injury type in our study.Knee, ankle ad foot injuries among these lower extremity injuries were more frequent similar to those stated by Rahmana (12) (Table 2).
In the study of Walden et al. (16), it was stated that 87% of time lost injuries affected the lower extremity and thigh being the most affected part (23%).In our study the most frequent injuries were again lower extremity injuries (Table 2).Although the thigh injuries among the mid-fielders were similar to the results of Walden et al. (16) the percentage of thigh injuries among other positions was higher (Table 2).
In the study of Inklaar et al. (9), it was stated that the most frequently injured body parts were thigh (23%), knee (22%) and ankle (23%).It was also stated that distribution of injured body parts was not related with age.In our study, although percentage being different among players in different positions, thigh, knee, foot-ankle injuries was more frequent.In addition leg injuries were also frequent (Table 2).It was stated that the most frequent injury types were sprains (31%), contusions (28%) and strains (19%) (9).In our study, although the percentages were different according to playing positions strains, tendon injuries and sprains were stated to be more frequent.However abrasions were detected to be more frequent.The reason for this may be due to different conditions of playing fields.Inklaar et al. (9) stated that sprain and strain injuries generally occurred in the same type and same body part and caused footballers' continuous sufferings.In our study, high frequencies of these types of injuries can be explained with the re-peated injuries regarding the same body part.
In the study of Hoy et al. (8) in which 646 male, 69 female footballers participated it was stated that the most frequently injured parts were joints (49%) and skin lesions (30%) were reported to be the second frequent type of injuries.Fractures were detected 18% and distributed equally within upper and lower extremities.In our study, the percentage of joint injuries of forwards were similar to those stated by Hoy et al. (8) whereas it was lower for other playing positions (Table 1).In our study, it was evident that skin lesions were the most frequent injury type for all playing positions (Table 1).
Besides percentage of fractures were lower than the results of Hoy et al. ( 8) (Table 1).
In the study of Schmidt-Olsen et al. (13) which was performed on 496 male footballers aged between 12-18 years, it was stated that most of the injuries occurred in lower extremities (70%), especially in knee (26%) and ankle (23.1%).In the same study head and neck injuries reported to occur 1.2%, upper extremity injuries reported to occur 10.3% and back problems constituted 14% of those injuries.Fractures were reported to exist only 4%, most of which were related with upper extremities.
Fractures supposed to occur as the young players were aware of the way to fall down (13).In our study it was evident that although being at low rates, most of the injures occurred at lower extremities (Table 4).Besides, our results regarding head and neck injuries and upper extremity injuries were higher than those of Schmidt-Olsen et al. (13).Considering the fractures, our results were said to be similar to the results of Schmidt-Olsen et al. ( 13) (Table 1).

Table 1 .
Types of injuries according to playing positions

Table 3 .
Total injuries in different playing positions according to anatomical localizations

Table 4 .
Total injuries according to anatomical localizations