Download Boys soccer league injuries: a community-based

European Journal of Public Health, Vol. 18, No. 1, 19–24
ß The Author 2007. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
doi:10.1093/eurpub/ckm050 Advance Access published on June 14, 2007
................................................................................................
Boys soccer league injuries: a community-based
study of time-loss from sports participation and
long-term sequelae
Toomas Timpka1, Olof Risto2, Maria Björmsjö1
Background: Youth soccer is important for keeping European children physically active. The aim of this
study is to examine injuries sustained in a community soccer league for boys with regard to age-related
incidence, time lost from participation and long-term sequelae. Methods: Primary injury data was
collected from a soccer league including 1800 players, comprising approximately 25% of all boys 13–16
years of age in three Swedish municipalities (population 150 000). Injuries were primarily identified
based on a time loss definition of sports injury. At the end of the season, a physician interviewed every
player who reported injured to determine whether there were any remaining sequelae. If a sequela was
confirmed, the physician repeated the interview 6, 18 and 48 months after the end of the season.
Results: Forty-four injuries were recorded during 18 720 player game hours (2.4 injuries per 1000 player
game hours). The highest injury incidence (6.8 injuries per 1000 player game hours) was recorded in the
first-year elite divisions. Thirty-two injuries (73%) were categorized as moderate-severe, and 21 injuries
(48%) required medical attention. Eight injuries caused sequelae that remained 6 months after the end
of the season, and 3 injuries caused sequelae that lasted 4 years after the injury event. Conclusion: An
overall low injury rate makes soccer a suitable sport for inclusion in programmes that promote physical
activity among children. When organizing soccer leagues for boys, injury prevention programmes
should be provided to adolescent players when they begin playing in competitive divisions.
Keywords: adolescents, cohort study design, football, sports injury epidemiology, sports safety
promotion
................................................................................................
igorous play, such as participation in physically challenging
V games and sports, is essential for physical, mental and
social development during childhood.1 In recent decades, the
prevalence of obesity and overweight among children and
adolescents has been increasing in Europe.2 One reason for this
development is a more sedentary lifestyle, where TVwatching
and computer games have come to replace physical activity.3
Community-based initiatives to stimulate physical exercise and
sports among the young are thus particularly important
countermeasures to wide-spread obesity.4 Soccer is the sport
with the largest number of participants worldwide. The
international federation of soccer associations, FIFA, estimates
the number of active players to more than 240 million,
representing 300 000 clubs in 204 countries [www.fifa.com
(accessed December 2006)]. Most of these players are
adolescents and youths. In Europe, almost all children are
exposed to soccer at school, and many children participate in
organized soccer practice and games in their free time.
However, young participants in sports are also known to be
at an increased risk for specific types of injuries, e.g. growth
plate and apophyseal injuries and heat illness.5 To avoid
unnecessary harm, it is today acknowledged that sports
participation by children should be guided by a gradual
increase of skills performance assessed after a responsible
preconditioning programme.6 In this context, it is unsatisfactory that the injury risk in youth soccer has seldom been
investigated from a community perspective, in order to adapt
physical exercise promotion programmes to reduce injury
1 Section of Social Medicine and Public Health, Department of Health
and Society, Linköping University, Sweden
2 Section of Orthopaedics, Faculty of Health Sciences, Linköping
University, Sweden
Correspondence: Toomas Timpka, Section of Social Medicine and
Public Health, Department of Health and Society, Linköping
University, SE-581 83 Linköping, Sweden, tel: þ46 13 222383,
fax: þ46 13 221865, e-mail: [email protected]
risks. Most studies of youth soccer injuries have been based on
small populations and short-term consequences.7 Nevertheless,
a number of player-specific factors associated with injury risk
have been identified, e.g. previous injury and an increasing
injury risk with age from late adolescence.8,9 It is also worrying
that a career as a soccer player into adulthood has been
reported to increase the risk for early development of
osteoarthritis caused by knee injuries, such as meniscus and
anterior cruciate ligament injuries and by high loads on knee
joints.10 A recent study indicates that the development of
osteoarthritis among adult ex-soccer players is associated with
poor health-related quality of life after retirement from the
sport.11
Despite the importance of youth soccer in keeping European
children physically active, the community-level significance of
injury side effects and the extent to which these injuries can
cause a player long-term sequelae have not been investigated.
Since this knowledge is available, adequate safety measures can
be implemented, thus improving the efficiency of physical
exercise promotion programmes among children. Even though
professional soccer academies for youth players have been in
operation for several decades, youth soccer in Europe is mainly
organized in amateur clubs. In these community settings,
coaches have limited education in injury prevention12 and
injury patterns are seldom recorded and analysed.13 The
responsibility for coordinating safety measures for youth
soccer competitions therefore lies on the community soccer
associations that organize the leagues. The aim of this study is
to examine the occurrence of injuries in a large community
youth soccer league with regard to age-related incidence, time
lost from participation and long-term sequelae. The study only
includes boys’ teams. The girls’ soccer league was in the study
community organized according to skill level and not age,
which meant that many adolescent girls played on senior-level
teams. Results are to be applied to planning community-level
programmes that promote physical activity among children
and youth sports.
20
European Journal of Public Health
Methods
A prospective cohort design was used for the study. The
primary data collection was conducted during the 2001 season
in the Swedish soccer association league for boys 13–16 years
of age in the Eastern district of Östergötland county, Sweden.
The injury definition included any injury occurring during
soccer games that resulted in one or more of the following:
medical attention, the inability to complete the game, or
missing a subsequent soccer session. The injuries were divided
into three severity categories based on a combination of time
lost and tissue damage definitions of sports injuries: minor
(1–7 days lost from soccer), moderate-severe (8 days or more
lost from soccer), and disabling (restricted function 6, 18 and
48 months after the season). This definition is compatible with
the time loss section in the international consensus definition
of soccer injury.14 The league included 93 teams and about
1800 players representing soccer clubs in three municipalities
(total population 150 000). The player population comprised
25% of all boys in the actual age intervals. During the study
season, there was one league pool for each birth year from
1988 to 1985 (U14–U17). The birth-year league pools were
divided into divisions of 8–12 teams each. According to league
rules, a team was allowed to use any number of under-aged
players and two over-aged players in each game.
The maximum number of players to be used in a game was
16, i.e. 11 starting players and 5 substitutes. Free substitution
was allowed during all games. The Eastern League district
cooperated with the Western League district of the regional
soccer association in forming an elite division for each group
of boys aged 15 and 16 years (U16–U17). To qualify for these
divisions, play-off divisions were arranged for U15 players.
694 games were played during the study season with a duration
of either 2 35 min (U14) or 2 40 min (U15–U17). One U17
team was excluded from the study due to a coach change in the
middle of the season.
Before the start of the season, the regional soccer association
office informed each club, the aims and procedures of the
injury registration. The protocol for the primary injury
identification prescribed that for each injury sustained
during the season, a questionnaire was to be completed by
the head team coach directly after the game. The data collected
included the time of injury, the injured player’s team position,
the coach’s judgement of the cause of injury, any rule-break
associated with the injury event, and whether or not the
injured player was wearing all prescribed and suggested
protective equipment. The anatomic location of the injury,
its type, and whether the player previously had sustained a
similar injury were also recorded. All questionnaires were sent
to the league office together with the official score sheets.
The game reports contained data on the name and birth year
of each participating player, penalties and scores.
Two weeks after the injury event, the reporting coach was
contacted to record the length of the player’s absence from
soccer. At the end of the season, interviews were conducted
with all head coaches to ensure that no injuries had been
missed. Thereafter, a physician interviewed every player
reported injured to investigate whether there were any
remaining sequelae. If a sequela was confirmed, the physician
repeated the interview 6, 18 and 48 months after the end of the
season. The final set of interviews was conducted in September
2005. The Regional Ethical Review Board in Linköping
approved the study protocol before data collection.
Injury incidence (injuries per 1000 player game hours) was
used to compare injury occurrence between the age-defined
league divisions. It was assumed that 11 players on each team
were at risk during the official game playing time for each
match. No adjustments for non-effective game time or penalty
time were made in the calculations. The study protocol did not
include recording the actual game playing time for any
individual player. Data on the identity of players and their age
was collected from official match reports. Confidence intervals
were calculated for estimates of injury incidence. To avoid
intra-player dependence (multiple reinjuries in individual
players) in the analyses, only one injury was accounted for
each player. All analyses were performed using the SPSS
software package (version 13.0).
Results
During the study season, 694 games were played with a
duration of either 2 35 min (U14) or 2 40 min (U15–U17).
Each team was exposed to injury risk during 14–22 games. The
total exposure to soccer corresponded to 18 720 player game
hours. In total, 44 injuries were recorded, corresponding to 2.4
injuries per 1000 player game hours (table 1). The highest
injury incidence (6.8 injuries per 1000 player game hours) was
recorded in the elite qualification divisions for U15 players.
Thirty-two injuries (73%) were categorized as moderatesevere, and 21 injuries (48%) received medical attention.
Injury causes and types
Sixty-eight percent of the injuries were contact injuries.
Collision was the most common cause of injury (29%),
followed by being kicked (24%) (table 2). Ten injury events
(23%) were reported to have been directly associated with
intentional foul play. The team position of the injured players
Table 1 Total and non-minor injury rates by age and skill level
Level
U14 community
U15 community
U15 elite qualification
U16 community
U16 elite
U17 elite
Total
Injuries
n
Risk exposure (hours)
Incidence/1000 h (95% CI)
Total
non-minor
Total
non-minor
Total
non-minor
Total
non-minor
Total
non-minor
Total
non-minor
Total
non-minor
9
5
0
0
16
14
4
4
9
5
6
4
44
32
5184
5184
2079
2079
2361
2361
2640
2640
3227
3227
3227
3227
18 718
18 718
1.7
1.0
0
0
6.8
6.0
1.5
1.5
2.8
1.6
1.9
1.2
2.4
1.7
0.8–3.3
0.3–2.3
0–1.8
0–1.8
3.9–11.0
3.2–9.9
0.4–3.9
0.4–3.9
1.3–5.3
0.5–3.6
0.7–4.0
0.3–3.2
1.7–3.2
1.2–2.4
Non-minor injuries (moderate-severe causing absence from practice or games longer than 1 week) are shown separately.
Boys community soccer league injuries
was not found to significantly influence the risk for sustaining
an injury, but there was a tendency for an increase in relative
injury risk among forwards. Playing in an attacking position
was associated with a 1.45 times higher (95% CI 0.71–2.96)
relative risk for injury than other playing positions.
Eight injuries (18%) were classified as reinjuries, but only
four of these primary injuries had been sustained during soccer
play. The two most common injury types were contusion
(29%) and ligament sprain (27%), followed by fracture (15%)
(table 3). Two of the six lateral ankle sprains were classified as
Table 2 Injury causes in numbers and percent (95% CI)
Injury cause
n
Percent
Collision
Blow, player
Strain
Fall
Blow, ball
Foul tackle
Turn
Other
NA
Total
12
10
5
4
3
2
1
4
3
44
29
24
12
10
7
5
2
10
100
NA ¼ not applicable for analysis.
Table 3 Injury types in numbers and percent
Injury type
n
Contusion
Sprain
Fracture
Rupture, tendon
Strain, muscle
Cut
Dental injury
Concussion
Other
NA
Total
12
11
6
4
2
2
1
1
2
3
44
Percent
n
Percent
29
27
15
10
5
5
2
2
5
9
9
6
3
2
1
–
–
2
28
28
19
9
6
3
–
–
6
100
32
100
Non-minor injuries (moderate-severe causing absence from
practice or games longer than 1 week) are shown separately.
NA ¼ not applicable for analysis.
21
grade 2–3 (ligament partially or completely torn), while the
remaining four sprains were classified as grade 1 (ligament
stretched). The six fractures consisted of two clavicle fractures,
two forearm fractures, one rib fracture and one fractured toe.
The body region most susceptible to injury was lower
extremities, accounting for 58% of all injuries, whereas the
trunk and head accounted for 30%, and the upper extremities
for 12% of all injuries (table 4).
Injury severity and remaining disability
The mean rehabilitation time off soccer practice or competition was 26.3 days (range 1–180 days). At the 48-month
follow-up interview, all 32 players who qualified for the
interview were physically active. For the injuries categorized as
moderate-severe, the absence period was 35.3 days (range
10–180 days). Eight (25%) of these 32 injuries caused a
restriction of physical performance (pain, decreased range of
motion, instability) that remained 6 months after the end of
the season (table 4), and the restriction remained 18 months
after the season for five (16%) injuries. Three injuries (9% of
all moderate-severe injuries) caused a reduction in function
that lasted 4 years after the injury event, corresponding to 0.2
disabling injuries per 1000 player game hours. One boy
sustained a reduction in the ability to rotate and flex his right
arm following a forearm fracture as a U14 player. Another U14
player who had injured three teeth was still under dental care.
This boy was still playing soccer. The third youth player who
reported remaining restricted function had suffered a grade
2–3 sprain of his right ankle as a U15 player. He was able to
return to his team following a 6-month rehabilitation period,
but had thereafter suffered from several spells of reinjury. Even
though at the time of the interview he was playing soccer with
a semi-rigid orthosis, he had relative ankle weakness and
reported occasional pain.
Discussion
Soccer is the most popular youth sport in Europe. The vision
of the European Federation of Football Associations (UEFA) is
that all children in Europe are offered the opportunity to play
soccer [www.uefa.com (accessed August 2006)]. In this
epidemiological study of a large community soccer league
involving approximately 25% of the adolescent boys in a
Swedish community, we found, similar to studies based on
Table 4 Anatomic injury localization displayed in numbers (percent)
Anatomic
location
Foot
Ankle
Hand/wrist/forearm
Heada
Knee
Lower back
Hip/groin
Lower leg
Thigh, front
Groin
Thigh, back
Abdomen
NA
Total
Total injuries
n (%)
7 (17)
6 (15)
5 (12)
5 (12)
4 (10)
3 (7)
3 (7)
2 (5)
2 (5)
2 (5)
1 (2)
1 (2)
3
44 (100)
Non-minor
injuries n (%)
7
4
5
1
2
3
3
2
2
1
1
1
(22)
(13)
(16)
(3)
(6)
(9)
(9)
(6)
(6)
(3)
(3)
(3)
32 (100)
after 6
months n (%)
Loss of function
after 18 months n (%)
after 48 months
n (%)
3
1
1
1
2
(37)
(12)
(12)
(12)
(25)
2 (40)
1 (20)
1 (20)
1 (33)
1 (33)
1 (33)
8 (100)
5 (100)
1 (20)
3 (100)
Non-minor injuries (moderate-severe causing absence from practice or games longer than 1 week), and injuries causing longterm loss of function due to tissue damage are shown separately.
a: Including dental injuries.
NA ¼ not applicable for analysis.
22
European Journal of Public Health
smaller populations,15,16 that the overall injury incidence was
relatively low. However, the majority of the recorded injuries
caused long absence from the short soccer season, and every
second injury required healthcare treatment. Three of the 1800
players participating in the league during the season sustained
an injury that caused a lasting restriction of physical function.
In a recent Canadian study involving a random sample of 21
adolescent soccer teams (aged 12–18), a certified athletic
therapist conducted weekly assessments of injuries sustained
during games and practice.17 The injury definition used was
the same as in the present study, i.e. the record included any
injury occurring in soccer that resulted in one or more of the
following: medical attention, the inability to complete a
session, or missing a subsequent session. The Canadian study
reported findings similar to ours regarding the association
between injury risk, age and level of competition. For instance,
the risk of injury in the U14 age group was the greatest in the
most elite division. An apparent difference is that a higher
game injury incidence (7.6 injuries per 1000 player game
hours) was reported in the Canadian setting. A closer analysis,
however, shows that 52% of all reported injuries resulted in an
absence of only 1 day. If these injuries are separated, the
incidence rate is reduced to 2.7 injuries per 1000 player game
hours. Moreover, the incidence of injuries causing seven or
more days absence reported in the Canadian study (1.3 injuries
per 1000 player hours) is lower than the corresponding
number found in the present study (1.7 injuries per 1000
player game hours). The difference in minor injury reporting
can be explained by the fact that a therapist examined all
injuries in the Canadian setting, while in the present study,
injuries were recorded by team coaches and players. In the
latter situation, the free substitution rule made it possible to
allow fatigued players with apparently self-limiting minor
injuries (minor contusions, bruises and blisters) to rest for the
remaining game without any further evaluation of the injury.
Even though the results from Canada and Sweden are similar
in many aspects, a remaining difference is that no fractures
were reported in the Canadian data. A possible explanation for
this can be that the Canadian study only covered slightly more
than one-fifth of the game exposure time covered by the
present study, thereby possibly missing rare injuries. However,
despite these differences, both studies indicate that while the
overall occurrence of non-minor injuries in boys youth soccer
is low, the injury incidence increases rapidly with the
introduction to an elite level of play. This implies that injury
prevention measures should particularly target players making
the transition to competitive league divisions. One possible
intervention could be to raise the age for separation of the
competitive divisions from the community league to the U17
level, when players are more mature. Such an intervention
would require the involvement of the soccer federations that
formulate policies and allocate resources in order to achieve a
coordinated implementation of programme actions. Such a
change in policy would have to take into account sport-specific
factors, e.g. the skill development of players aiming for a
professional career.18
Physical contact with opponent players through collisions,
blows and foul tackles caused 63% of the injuries in the youth
league. Consequently, moderation of aggressive and careless
play has the potential to decrease injury rates. It has been
pointed out that coaches play a central role for socialization in
youth soccer.19 An obvious opportunity to moderate aggressive
play is, therefore, to influence the behaviour of the coaches in
the dressing room and during games. Fair play means accepting
responsibility for the long-term internal and moral interests of a
particular sport.20 In youth soccer, taking this responsibility
would require a behaviour that promotes the sport as a
diversion intended to be fun and pleasurable for all participants,
and that a spirit of moderation and generosity should dominate
it (www.fifa.com [accessed December 2006)]. If fair-play norms
are to have any impact, the principles of sportsmanship have to
be honoured by all participants and contributors to the youth
soccer league, from the soccer federations and league organizers
to the coaches, parents and players. It is possible that increasing
competition and the pressure to win experienced by youth
coaches may be an obstacle to teaching fairness, and the
opposite may be conveyed to many young athletes.
Commitment to the moral principles of sportsmanship
among the young is an acknowledged goal for school physical
education, and school programmes have also been reported
successful with regard to changes in moral development in
children between grades 4 and 6.21 Nevertheless, few studies
have addressed the impact of fair-play interventions in the
youth sports context. It has been shown that certified youth
coaches, in general, rank having fun, learning life skills, being
part of a team, developing confidence, and the excitement of
competition as the most important outcomes for the youth they
coach.22 However, the vast majority of youth soccer clubs in the
study setting, as in most European countries, rely primarily on
parent volunteers to serve as coaches. Most of these volunteer
coaches have not received formal training to prepare them for
all aspects of the role as a youth sports coach. The self-described
needs and concerns of these volunteer coaches have recently
been described.23 It should thus be possible to provide more
training for volunteer coaches in accepting responsibility for the
long-term internal and moral interests of the sport, e.g. in
containing or preventing inappropriate parent behaviours.
The training of volunteer coaches should also include information on injury risks and risk factors. Under-estimation of injury
risk has been found to be associated with a increase in risk of
injury in the youth soccer context.24
The mean period of absence from soccer recorded in the
present study was 26.3 days. This number is close to the mean
period of absence of 21.9 days recorded in a prospective study of
3805 injuries sustained in English youth academy football.25
Even though the rate of reinjury was only 3% in that study (as
compared to 18% in the present one), the English youth
academy study concluded that the links between tissue damage,
rehabilitation, musculoskeletal development and the onset of
youth-related conditions such as Sever’s disease and Osgood–
Schlatter’s disease deserve further attention. This suggestion is
also warranted in light of our findings. It is possible that the
disability caused by the forearm fracture observed in this study
could have been avoided if the fusion of the ossified epiphyses to
the shaft of the bone had been staged,26 and closely followed in
parallel to the healing of the fracture. Similarly, even though
ankle sprains are generally believed to be benign and selflimiting, several studies report a significant proportion of
athletes with ankle sprains that have persistent symptoms for
years.27 Closer examination of ankle sprains is also recommended, in accordance with our data, where two players
reported repeated reinjuries and one player a lasting disability.
Such surveillance would involve immediate examination, a
diagnosis including grading of the sprain, early introduction of
treatment and regular follow-ups. As regards treatment of
inversion ankle sprains, controlled studies28,29 report positive
effects both from the use of semi-rigid orthosis, and coordination training using ankle discs. The injury rates and types
recorded in this study suggest that regular medical surveillance
is not required during boys’ soccer league games, while coaches
and officials should have basic training in the management of
sports injuries. In contrast, clubs with teams in competitive
league divisions should be able to consult a physiotherapist or
physician specialist in sports medicine in order to customise
individual rehabilitation programmes for players with longterm injuries.
Boys community soccer league injuries
This study has several limitations that must be taken into
consideration when interpreting results. Since it was found
impractical to record exposure data from soccer practice in the
community setting, injuries sustained during practice sessions
were not included in the data collection. The incidence of
practice injuries in youth soccer has been reported to be
considerably lower than during games.8,17 However, the
exclusion of data from practice settings may lead to overuse
injuries being under-reported, since children found to be
suffering from progressively developing overuse symptoms are
probably advised to rest from games and practice. Also, only
two concussions were reported in the present study, one of these
as a secondary finding to a cut on the forehead. Both of these
injured players were allowed by their coaches and parents to
return to play within 2 weeks. An additional limitation of the
present study is that the coaches had not received training in
evaluating any possible concussions. Recent studies have
pointed out that when evaluating the effects of blows to the
head, symptoms of headache > 3 h, difficulty concentrating
> 3 h, retrograde amnesia, or loss of consciousness indicate a
more severe injury.30 The report card used in this study did not
include this level of specificity. Future studies of community
youth soccer injuries, however, must be extended with these
variables for the assessment of concussion signs and symptoms
based on return-to-play timelines.
Soccer provides an important opportunity for physical
exercise and leisure for large groups of European children and
adolescents. We found that the occurrence of non-minor
injuries in a large community youth soccer league was low, but
also that the incidence increased with age and level of
competition. By focussing the study design on a large
population and a long-term follow-up, we were able to
record sequelae of rare but important non-self limiting
injuries, e.g. fractures and dental injuries. Findings suggest
that soccer is a suitable sport for inclusion in programmes that
promote physical activity among children. However, when
organizing soccer leagues for boys, injury prevention programmes should be provided to adolescent players when they
begin playing in competitive divisions. Such programmes
should be evidence-based,31 and be planned in cooperation
with the relevant soccer federations responsible for league
administration.
Acknowledgements
The study was supported by a grant from The Swedish Centre
for Sports Research (CIF).
Conflict of interest: None declared.
Key points
Youth soccer injuries have seldom been investigated
from a community perspective with the purpose of
adapting physical exercise promotion programmes to
reduce hazards.
In a large community youth soccer league, we found a
low occurrence of non-minor injuries, but the
incidence increased with the level of competition
and injuries causing long-term sequelae were rare but
consequential.
The overall low injury rate makes soccer a suitable
sport for inclusion in programmes that promote
physical activity among children.
Injury prevention programmes should be provided to
adolescent soccer players when they begin playing in
competitive league divisions.
23
References
1
Pellegrini AD, Smith PK. Physical activity play: the nature and function of a
neglected aspect of play. Child Dev 1998;69:577–98.
2
Janssen I, Katzmarzyk PT, Boyce WF, et al. Health behaviour in
school-aged children obesity working group. Comparison of overweight
and obesity prevalence in school-aged youth from 34 countries and their
relationships with physical activity and dietary patterns. Obes Rev
2005;6:123–32.
3
Fox KR. Childhood obesity and the role of physical activity. J Roy Soc Health
2004;124:34–9.
4
Flynn MAT, McNeill DA, Maloff B, et al. Reducing obesity and related
chronic disease risk in children and youth: a synthesis of evidence with ‘best
practice’ recommendations. Obes Rev 2006;7(suppl 1): 7–66.
5
Demorest RA, Landry GL. Prevention of pediatric sports injuries. Curr Sports
Med Rep 2003;2:337–43.
6
Dollard MD, Pontell D, Hallivis R. Preconditioning principles for preventing
sports injuries in adolescents and children. Clin Pediatr Med Surg
2006;23:191–207.
7
Giza E, Micheli LJ. Soccer injuries. Med Sport Sci 2005;49:140–69.
8
Dvorak J, Junge A. Football injuries and physical symptoms. A review of the
literature. Am J Sports Med 2000;28:S3–9.
9
Kucera KL, Marshall SW, Kirkendall DT, et al. Injury history
as a risk factor for incident injury in youth soccer. Br J Sports Med
2005;39:462.
10 Roos H. Are there long-term sequelae from soccer?. Clin Sports Med
1998;17:819–31.
11 Turner AP, Barlow JH, Heathcote-Elliott C. Long term health impact of
playing professional football in the United Kingdom. Br J Sports Med
2000;34:332–6.
12 Cunningham A. An audit of first aid qualifications and knowledge among
team officials in two English youth football leagues: a preliminary study. Br J
Sports Med 2002;36:295–300.
13 Finch CF, Hennessy M. The safety practices of sporting clubs/centres in the
city of Hume. J Sci Med Sport 2000;3:9–16.
14 Fuller CW, Ekstrand J, Junge A, et al. Consensus statement on injury
definitions and data collection procedures in studies of football (soccer)
injuries. Br J Sports Med 2006;40:193–201.
15 Peterson L, Junge A, Chomiak J, et al. Incidence of football injuries and
complaints in different age and skill-level groups. An J Sports Med
2000;28:S51–7.
16 Kibler WB. Injuries in adolescent and preadolescent soccer players. Med Sci
Sport Exer 1993;25:1330–2.
17 Emery CA, Meeuwisse WH, Hartmann SE. Evaluation of risk factors for
injury in adolescent soccer: implementation and validation of an injury
surveillance system. Am J Sports Med 2005;33:1–10.
18 Timpka T, Ekstrand J, Svanstrom L. From sports injury prevention to safety
promotion in sports. Sports Med 2006;36:733–45.
19 Pilz GA. Nurturing fair play in competitive sports. Results from a study on
competitively oriented youth soccer [article in German].
Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz
2005;48:881–90.
20 Keating JW. Sportsmanship as a moral category. In: Morgan WJ, Meier KV,
editors. Philosophic inquiry in sports. Champaign, IL: Human Kinetics Press,
1995: 144–51.
21 Gibbons SL, Ebbeck V, Weiss MR. Fair play for kids: effects on the moral
development of children in physical education. Res Q Exerc Sport
1995;66:247–55.
22 Lesyk JJ, Kornspan AS. Coaches’ expectations and beliefs regarding benefits
of youth sport participation. Percept Mot Skill 2000;90:399–402.
23 Wiersma LD, Sherman CP. Volunteer youth sport coaches’ perspectives of
coaching education/certification and parental codes of conduct. Res Q Exer
Sport 2005;76:324–38.
24 Kontos AP. Perceived risk, risk taking, estimation of ability
and injury among adolescent sport participants. J Pediatr Psychol
2004;29:447–55.
24
European Journal of Public Health
25 Price RJ, Hawkins RD, Hulse MA, et al. The Football Association medical
research programme: an audit of injuries in academy youth football. Br J
Sports Med 2004;38:466–71.
29 Handoll HH, Rowe BH, Quinn KM, et al. Interventions to prevent ankle
sprains. Cochrane Database Syst Rev 2001;3:CD000018.
26 Pappas AM. Elbow problems associated with baseball during childhood and
adolescence. Clin Orthop Relat Res 1982;164:30–41.
30 Asplund CA, McKeag DB, Olsen CH. Sport-related concussion:
factors associated with prolonged return to play. Clin J Sport Med
2004;14:339–43.
27 Anandacoomarasamy A, Barnsley L. Long term outcomes of inversion ankle
injuries. Br J Sports Med 2005;39:e14.
31 Finch C. A new framework for research leading to sports injury prevention.
J Sci Med Sport 2006;9:3–9.
28 Tropp H, Askling C, Gillquist J. Prevention of ankle sprains. Am J Sports Med
1985;13:259–62.
Received 1 September 2006, accepted 30 April 2007