Exclusive: Injury research suggests training not keeping up with demands of elite women’s game
Sat 27 May 2023 02.00 EDT
Coaching methods are failing to keep up with the rapidly increasing demands of women’s professional football, resulting in more hamstring injuries among top female players. Experts are calling for women to be trained at a higher level to prevent such injuries.
The incidence of hamstring injuries in female footballers has historically been lower than in men, but these figures are changing at the elite level and the incidence is now similar. They are the most common injury subtype among elite-level female players, accounting for 12-16% of all time-loss injuries.
“A team with a 19- to 22-player squad can typically expect three to four hamstring injuries each season,” said Prof Jan Ekstrand at Linköping University in Sweden, who led the research.
It was commissioned by the Union of European Football Associations (Uefa) to investigate the factors underpinning these injuries and identify potential ways to improve player safety.
Ekstrand and colleagues at Isokinetic Medical Group in London and the Football Research Group at Linköping examined exposure and injury data for the 2020-21 season from 11 leading European women’s teams – including Chelsea, Manchester City, Bayern Munich, Olympique Lyonnais and Barcelona. They also asked their chief medical officers which of 21 modifiable risk factors they believed contributed to these injuries and to what degree.
The study, published in the journal Knee Surgery, Sports Traumatology, Arthroscopy, concluded that most risk factors for hamstring injuries were extrinsic in nature and associated with the club, the team and the coaching staff rather than the players themselves.
It cited as key contributory factors a lack of regular exposure to high-speed football actions during training; playing matches two to three times a week; load on players; and lack of communication between medical and coaching staff.
Other research has suggested the physical demands of elite-level women’s football have increased. For instance, Fifa’s analysis of the 2019 Women’s World Cup in France found that the distances teams covered in the highest speed zone increased by almost 30% compared with the 2015 World Cup.
“Women are playing more games than they ever have done, but if you increase the workload demand, that is definitely a risk factor for injuries,” said Dr Matthew Stride, a consultant in sport and exercise medicine at Isokinetic London and former club doctor to Brentford and the England women’s under-21 and under-16 teams; Stride was not involved in the study.
“These are also issues within the men’s game, but they’ve got nearly 20 years more injury data surveillance to draw on. In the modern era, the more successful coaches are the ones that have embraced sports science and have regular dialogue with the medical team.”
Ekstrand and his colleagues explained that fatigue was implicated in the majority of hamstring injuries. They said: “The coaches control numerous variables that may lead to fatigue – excessive training, too many matches, muscle overload, or poor training periodisation leading to under-training and muscular dysfunction. All these factors are potentially modifiable.
“Hamstring injuries mostly occur during sprinting and other high-velocity actions. Therefore, regular and consistent exposure to high-speed football actions prepares the hamstrings for similar moves occurring during games. Lack of sufficient high-speed play during training increases the risk for hamstring injury during the competition. Training should mimic match play to adapt the muscles to the game demand; also this factor is mainly controlled by coaches.”
They also recommended implementation of the Nordic hamstrings exercise protocol, which is designed to strengthen the hamstrings when they are in the eccentric (lengthened) position.
“It has been shown on numerous studies now that if you go through progressive phases of doing these Nordic hamstring exercises – be it preseason or throughout the season – squads have had lower rates of hamstring injury,” Stride said.
Dr Jesus Olmo, a former Real Madrid medical director and a sports doctor at Isokinetic London, which specialises in injury prevention, treatment and rehabilitation of injuries, said: “It is essential that as women compete in football in highly competitive and elite levels that we provide an infrastructure that is going to support them.
“We believe that prevention is key and it is crucial to assess players before they experience injury to better understand their unique movement patterns and strategise optimised ways of movement that will keep the individual healthy for longer.”
How to protect your hamstrings
The hamstrings are a group of three muscles and their associated tendons which run down the back of the thigh and wrap around the knee. Together they work to pull the leg backwards and propel the body forwards during walking or running, and flex the knee. Because they cross over both the hip and knee joint, they are particularly susceptible to injury – especially during sudden explosive movements such as sprinting, lunging or jumping.
Stride says: “Generally speaking, you will not injure your hamstrings jogging at a slowish speed – hamstring strains and tears tend to occur during sudden movements, such as when athletes are sprinting after a ball or an opponent.” Football, basketball and rugby players are at particularly high risk.
There are two main classes of injury, says Stride: functional injuries, usually caused by damage or irritation of the sciatic nerve that runs through the hamstrings; and structural injuries, where the muscle fibres are strained or torn to varying degrees. In severe cases, athletes may feel a “pop” and describe a sudden sharp or stabbing pain in the back of the thigh.
To minimise the risk of injury, Stride recommends making sure the leg muscles are fully warmed up before sprinting, and building up fitness levels gradually, before participating in high intensity activities such as fast-paced football games or bootcamps.
There are also specific exercises you can do, such as the Nordic hamstring exercise, which aims to strengthen these muscles.
To do this, kneel on the ground, with something or someone holding down your ankles, and then slowly lean forwards with a straight back, for as long as you feel you can control the movement. Push back up with your hands and repeat.
Another risk factor is having a weak gluteus maximus – the big fleshy muscle that makes up most of the shape of the buttocks. “Its main role is to stabilise the pelvis and hip, and should be the primary muscle involved in hip extension,” says Stride.
“But if that muscle is not warmed up properly, or is weak or dysfunctional, it places higher load and stress through the hamstrings when someone is running or sprinting.”