Following the recent publication of the study into injuries and illnesses in English women’s domestic football, we sat down with our Chief Medical Officer, Dr Charlotte Cowie to discuss the findings.
The research was published by Nottingham Trent University and commissioned by the FA.
Charlotte, the FA has overseen an important surveillance study into injuries in domestic women’s football in England. Can you give us a summary of the study and its findings?
In collaboration with Nottingham Trent University, we introduced an injury and illness surveillance programme to better understand the incidence, severity, and burden of injury in English women’s domestic professional football. Injuries were collected from across the Barclays Women’s Super League and the Barclays Women’s Championship across five seasons (2018-2023).
The data has been collated by Nottingham Trent University who have independently and anonymously amalgamated it, assessed it and published the important findings in a peer reviewed journal. The study provides the most up-to-date and comprehensive surveillance of injuries in English women’s domestic football, and we believe this is a benchmark against which the success of future injury prevention strategies will be assessed.
The study found that injury incidence and burden (the time an injury takes to recover) were greater in matches than in training, with incidence showing a non-significant 8% decrease in match-play and significant 28% decrease in training per season in English women’s domestic football. Hamstring injuries are the most common injury diagnosis, and ACL injuries are the most burdensome, which illustrates the need to continue to develop prevention strategies for these injuries.
Much has been discussed about a possible ‘ACL epidemic’ in the women’s professional game, and what this study shows is that although the number of ACL injuries have increased, this may be because the amount of match-play taking place in women’s professional football in England has increased. So, to be clear, when calculating the rate of injuries per 1,000 hours playing time, no statistical differences have been shown over time from season to season.
What is the background to the study and how important was it for the FA to lead this research?
The first thing I'd say is that in a number of sports within the UK and other countries, national governing bodies put in place injury surveillance studies like the one we have conducted to try and make sure that they've got an overview of the typical injuries that happen within their sport and to understand how injuries might be changing as their sport develops over time.
The helpful thing about having a large study like this is that, although you haven't got significant detail about each and every individual injury, you do get a large overview of the game as a whole, so it's the type of study that only a national governing body or similar overarching organisation can do.
Clubs collect their own injury statistics, but they'd only have a small pool of players to draw from, so it's very hard for them to get big data and understand the broader statistical significance of the data they're collecting. It's something that you can only really do by collecting a lot of data points across the whole game to help us highlight what the major injuries are. Once we’ve delved into those injury patterns, we can aim to put interventions in place to try and reduce injury, and it helps us to monitor the success of those interventions as well.
This type of study is only effective if it runs for a long period of time, but coordination of this is harder in the English professional game where you've got a lot of different organisations who have to collaborate together to collect their data in the same way. The big step forward with injury surveillance in English professional football overall has been the collaboration with the Premier League, the EFL, and the women's professional leagues to make sure that alongside our England teams, we've got people collecting data in the same way and collecting it regularly, so that we have a comprehensive picture of the professional game across all levels. The fact that leagues have mandated this data collection for clubs has been key to this. It means that we can compare injury statistics between the men’s and women’s game, between national and international duty and between youth and adult players.
The number of ACL injuries is something that has been highlighted in recent years. How much of a concern was that throughout the study?
The study pulls every single injury and illness that occurs across the whole of the game through into the study, so naturally ACL injury has always been part of the data that's collected. The decision to focus some of the reporting on the element around ACLs is to try and answer some of the questions that started to rise out of what appeared to be an increase in incidents. There was a cluster of occurrences and questions about whether those ACL injuries were related to an increased density of matches. ACL injury is not a frequent injury, but when it happens it is serious because it keeps people out for a long period of time, and in some cases is career-threatening. Because it’s infrequent in comparison to other injuries, a big study like this over a period time is the only way to get an accurate understanding of the rates of injury.
The really helpful thing from this is that it's been able to give us a bit of perspective and show us that although it felt as though ACLs were increasing, actually when you look at it over the time that we've been collecting data, the rate of injury has remained about the same all the way through.
Have the development and changes in the elite women's game which has happened over the last decade affected rates of injury?
So far, the current data in the women’s game is just a start. We’ll keep on collecting data year-on-year and it will help us to develop a picture of injury in the women's game as it continues to progress and transform over the next few years. To establish how our baseline develops over the coming years and decades, it’s really important to understand how the demands of the game affect injury rates. We always encourage clubs to continue to submit their data to the surveillance study.
How significant can the findings be in terms of the future of the women's game in terms of prevention of injuries?
I think it's important for us to keep an eye on how things are developing year-on-year. For example, hamstring injuries are another real key area of interest and if there is a trend with any injury, then the injury surveillance project will be instrumental in flagging those concerns. If we see a sudden upward trend in one injury or the severity of a particular injury, then it's for us to launch investigations and use different tools that can delve deeper and understand the reasons behind some of those trends.
All this data is anonymised, so we can't investigate individual players and individual injuries, but the trends give an overall indication that we need to do specific research in a particular area and that's how we would then justify looking into those areas further.
The FA funded the study and worked with Nottingham Trent University, how important was it to have all the input of the University?
It was very important. They're an independent academic body that collect the data independently and anonymously amalgamate it, assess it and then publish the important findings in peer reviewed journals. We can't do it without external partners who have the capacity to do that. And then the other big buy-in is obviously from the individual clubs who will not only submit their injury data, but also data on how many hours their players have trained during the week. This is quite a commitment for them to make week-on-week all the way through the season, so we rely on all of those different stakeholders to do their bit to make the study work. We’re grateful to them all for their support and continued collaboration.
What else are the FA doing to further understand and support the prevalence of all injuries in the women’s game?
One of the key concerns within the women’s game is still ACL injury because studies show that it is more common in female than male players and because the burden (as explained above) is so high. As a result, we're launching a PhD alongside Imperial College and in collaboration with the women’s professional leagues to look a little bit deeper into ACL injury’s impact on individual players. The study will have the objective to try and find out a little bit more about their lived experience with the injury, of what support they have had, what support they have lacked and the difficulties they've faced. The idea is to come out with some recommendations about how resource would be best spent within the women's professional leagues to support those players better in the future. This is an example of the type of ‘deep dive’ we can take into a particular injury as we look at the results of surveillance over time.
Will the information from the study be shared with other national associations, and bodies like FIFA and UEFA?
The peer reviewed publication means that the information is available to everyone. Until very recently, we've not had sufficient stats to really bring this together and share it as a really significant piece of work. This is our first publication exclusively in the women's game, even though it's been going on for quite a while. We hope that as time goes on, we'll have more and more to share with them. The other thing that we do think is important is to share the reports and also individual club reports with the clubs too so that they can get the individual benefits of having contributed to the study.
What about our ongoing work around concussion in football and how does this fit into the report?
The FA guidelines on concussion management have developed over a number of years, working with experts in the field, and they provide comprehensive and prescriptive guidance on the identification and management of a concussion. The professional leagues, across English football, have mandated the guidelines which is really positive . It means that every concussion, wherever it happens within the men's or women's professional game, should be managed with the same standardised approach. Those methods are also taught on our FA emergency pitchside care courses, which are also mandated across the professional game for any medical professional who is pitchside at a match.
This means that everybody understands the standard that they are working to. They've been trained in managing concussion in the same way so that, for instance, where two doctors or physios are working at the same match, they will both have an understanding of how concussion should be managed on-pitch and then off-pitch and will be using the same techniques and language. We're really pleased that all of our stakeholders have adopted those FA guidelines and they are a consistent thread that runs throughout the whole of the professional game.
