THIEME

682 Original Article

Ankle Sprains in Brazilian Professional Soccer:

Epidemiological Analysis of 126,357 Match Hours
Entorses do tornozelo no futebol profissional brasileiro:
Análise epidemiológica de 126.357 horas de jogo
Ewerton Borges de Souza Lima1 Gabriel de Melo Salgado2 Eduardo Patrício Mello2
Paulo Henrique Schmidt Lara 1 Gustavo Gonçalves Arliani1 Moisés Cohen2

1 Department of Orthopedics and Traumatology, Sports Address for correspondence Ewerton Borges de Souza Lima, MD,
Traumatology Center, Escola Paulista de Medicina, Universidade Department of Orthopedics and Traumatology, Sports Traumatology
Federal de São Paulo, São Paulo, SP, Brazil Center, Escola Paulista de Medicina, Universidade Federal de São
2 Department of Orthopedics and Traumatology, Escola Paulista de Paulo, R. Estado de Israel, 713 - Vila Clementino, 04022-00, 1São
Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil Paulo, SP, Brazil (e-mail: ewertonbslima@gmail.com).

Rev Bras Ortop 2024;59(5):e682–e688.

Abstract Objective This study aimed to perform an epidemiological analysis of ankle sprains in
professional soccer players in Brazil.
Methods This prospective epidemiological study analyzed ankle sprains in profes-
sional male soccer athletes during the Brazilian Championship and the Paulista Football
Championship from 2016 to 2019. All on-pitch medical care provided in official
matches was recorded. The variables evaluated included the age and position of the
player, injury diagnosis, pitch site where the injury occurred, playing time, imaging
tests performed, surgical treatment, time away from competitions, and injury recur-
rence. We assessed the incidence of injuries according to the Federation Internationale
de Football Association (FIFA) incidence formula.
Results Ankle sprains represented 10.17% of total injuries, with a FIFA index equal to
2,002. Lateral ligament injuries represented 53.75% of all sprains. The forwards were
the most injured athletes, with 86 lesions. The midfield had the highest number of
Keywords sprains (75.50%). Almost half (47.04%) of sprains occurred in the final 15 minutes of
► ankle injuries each half-time. Injuries recurred in 31.22% of cases, and 7.11% of injuries underwent
► epidemiology surgical treatment. The average time away from competitions was 13.95 days.
► soccer Conclusions Ankle sprains are common injuries in soccer. Although the average time
► sports to return to sport is brief, these injuries have a high recurrence rate and are potentially
► sports medicine surgical, leading to a longer time off competitions.

Work carried out at the Sports Traumatology Center, Department

of Orthopedics and Traumatology, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, SP, Brazil.

received DOI https://doi.org/ © 2024. The Author(s).

May 30, 2023 10.1055/s-0044-1785660. This is an open access article published by Thieme under the terms of the
accepted ISSN 0102-3616. Creative Commons Attribution 4.0 International License, permitting copying
September 25, 2023 and reproduction so long as the original work is given appropriate credit
(https://creativecommons.org/licenses/by/4.0/).
Thieme Revinter Publicações Ltda., Rua do Matoso 170, Rio de
Janeiro, RJ, CEP 20270-135, Brazil
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Resumo Objetivo Realizar análise epidemiológica das entorses de tornozelo em jogadores

profissionais de futebol no Brasil.
Métodos Estudo epidemiológico prospectivo das entorses de tornozelo em atletas
profissionais de futebol masculino ocorridas no Campeonato Brasileiro e no Campeo-
nato Paulista de Futebol, entre 2016 e 2019. Foram registrados todos os atendimentos
médicos em campo realizados durante partidas oficiais. As variáveis avaliadas foram:
idade e posição do jogador, diagnóstico da lesão, lateralidade, local em campo onde
ocorreu a lesão, tempo de jogo, exames de imagem realizados, realização de
tratamento cirúrgico, tempo de afastamento e recorrência da lesão. A incidência
das lesões foi avaliada de acordo com a fórmula de incidência da Federation Interna-
tionale de Football Association (FIFA).
Resultados As entorses de tornozelo representaram 10,17% do total de lesões, com
índice FIFA ¼ 2.002. As lesões ligamentares laterais representaram 53,75% do total das
entorses. Os atacantes foram os mais lesionados, com 86 lesões. O meio de campo foi o
local com maior número de entorses (75,50%). Nos 15 minutos finais de cada tempo,
Palavras-chave ocorreram 47,04% das entorses. As lesões foram reincidentes em 31,22% dos casos, e
► epidemiologia 7,11% das lesões foram tratadas cirurgicamente. O tempo médio de afastamento foi de
► esportes 13,95 dias.
► futebol Conclusões As entorses de tornozelo são lesões frequentes no futebol. Apesar do
► medicina do esporte tempo médio para retorno ao esporte ser breve, essas lesões apresentam grande taxa
► traumatismos do de reincidência e são potencialmente cirúrgicas, o que está associado a maior tempo
tornozelo de afastamento.

Introduction Futebol in Portuguese) and Paulista Football Championship

(CPF, for Campeonato Paulista de Futebol), from 2016 to
Football is the most popular sport in the world, with 240 2019. The Research Ethics Committee approved this study
million amateur athletes and around 200,000 professional under registration CAAE 56723616.3.0000.5505. All partic-
ones.1 Added to its popularity, it has a high rate of injuries. In ipants included in the study signed the informed consent
recent years, the physical demands have increased, forcing form.
athletes to work close to their maximum exhaustion limits, All on-pitch medical care provided during official matches
increasing the predisposition to injuries. was recorded. Club doctors received training to fill out two
Several movements occur during a football match, requir- forms on two online platforms, Transfermarkt (Transfer-
ing sudden changes in direction, on average, every 6 sec- markt GmbH & Co. KG, Hamburg, Germany) and SurveyMon-
onds.2 In this scenario, the injury mechanisms favor the key (Momentive AI., San Mateo, CA, USA). The first form was
involvement of the lower limbs, especially the ankles. These filled out immediately after each match, and the second form
lesions correspond to around 13% of injuries in football, only was filled out after the athlete returned to the sport. The
behind thigh and knee injuries.3 In addition to the impact on collection occurred throughout the championship, and we
the athlete’s career, these injuries result in high costs for contacted the doctors monthly to remind them to fill out the
clubs due to treatment and rehabilitation. Understanding the forms.
epidemiology and incidence of ankle injuries can help clubs All players with injuries resulting from ankle sprains were
prepare their athletes in a targeted manner. Therefore, this included in the study, regardless of age. The variables evaluated
study aimed to perform an epidemiological analysis of ankle were age and position of the player, injury diagnosis, laterality,
sprains in professional football players in the main Brazilian pitch site where the injury occurred, playing time, imaging tests
championships from 2016 to 2019. performed, surgical treatment, time away from the competition,
and injury recurrence. For this study, injury was defined as a
musculoskeletal complaint occurring during a match that
Materials and Methods
resulted in a player missing at least one match or training
This prospective epidemiological study evaluated ankle session. We assessed the incidence of injuries using the FIFA
sprains in professional male football athletes in two divisions incidence formula ¼ (total injuries x 1,000)/total hours played.
of two men’s football championships with significant social The descriptive statistical analysis of quantitative varia-
and economic relevance in Brazil, that is, the Brazilian bles was performed in Excel 2016 (Microsoft Corporation,
Football Championship (CBF, for Campeonato Brasileiro de Redmond, WA, USA). We used the IBM SPSS Statistics for

Rev Bras Ortop Vol. 59 No. 5/2024 © 2024. The Author(s).

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Vol. 59
Table 1 Main characteristics, pitch site where the injuries occurred, and their relationships with the diagnoses and positions of the players

No. 5/2024
Diagnosis n (%) FIFA index Recurrence Surgery Time away Pitch site
Attack area Attack midfield Defense midfield Defensive area
Simple sprain 73 (28.85%) 0.578 28 (11.07%) 0 6.78 19 (7.51%) 21 (8.30%) 22 (8.70%) 45 (17.79%)
Unimalleolar ankle fracture 8 (3.16%) 0.016 0 6 (2.37%) 105 3 (1.19%) 6 (2.37%) 3 (1.19%) 9 (3.56%)
Bimalleolar ankle fracture 2 (0.79%) 0.063 0 2 (0.79%) 89 0 2 (0.79%) 0 0

© 2024. The Author(s).

Lateral ligament lesion 136 (53.75%) 1.076 44 (17.39%) 5 (1.98%) 10.44 1 (0.40%) 0 0 1 (0.40%)
Medial ligament lesion 26 (10.28%) 0.206 6 (2.37%) 2 (0.79%) 16.27 0 0 1 (0.40%) 3 (1.19%)
Syndesmosis injury 8 (3.16%) 0.063 1 (0.40%) 3 (1.19%) 37.75 8 (3.16%) 7 (2.77%) 8 (3.16%) 15 (5.93%)
Position
Striker 86 (33.99%) 0.680 23 (9.09%) 5 (1.98%) 10.92 23 (9.09%) 32 (12.65%) 30 (11.86%) 3 (1.19%)
Midfielder 44 (17.39%) 0.348 17 (6.72%) 4 (1.58%) 15.86 1 (0.40%) 16 (6.32%) 23 (9.09%) 4 (1.58%)
Defensive midfielder 33 (13.04%) 0.261 8 (3.16%) 2 (0.79%) 13.52 0 7 (2.77%) 25 (9.88%) 1 (0.40%)
Wing 50 (19.76%) 0.396 17 (6.72%) 4 (1.58%) 14.32 4 (1.58%) 4 (1.58%) 25 (9.88%) 17 (6.72%)
Defender 30 (11.85%) 0.237 9 (3.56%) 3 (1.19%) 22.50 1 (0.40%) 10 (3.95%) 15 (5.93%) 4 (1.58%)
Goalkeeper 10 (3.95%) 0.079 5 (1.98%) 0 (0%) 5.6 0 1 (0.40%) 3 (1.19%) 6 (2.37%)

Note: Percentages referred to the total number of ankle injuries assessed. The average age is given in years. The average time away from competition is given in days.
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Windows Version 20.0 software (IBM Corp., Armonk, NY, total sprains, followed by simple sprains (sprains with no
USA) for the statistical inference of continuous variables. diagnosis of ligament injury, fractures, or other associated
Qualitative variables were analyzed using the chi-square injuries), accounting for 28.85% of cases. Other diagnoses
test, and the analysis of variance (ANOVA) test was used include medial ligament lesions (MLLs), unimalleolar frac-
for multivariate analysis, defining a 95% confidence interval tures, bimalleolar fractures, and syndesmosis injuries
and a 5% significance (p < 0.05). The Shapiro-Wilk test deter- (►Table 1).
mined the normality of the sample. The average age of the injured players was 25.94 years old.
The study took place during 4 CBF seasons, with the Different injuries had a similar distribution between age
participation of 20 clubs per year in each division. Each groups. Imaging exams were requested in 94.07% of the
club played 38 matches per season. In the same period, there lesions, totaling 391 exams performed (►Table 2).
were 4 CPF seasons, with the participation of 16 to 20 clubs
per year in each division. Each club played 17 to 22 matches Player Position, Pitch Site, and Time of Injury
per season. In total, we analyzed 15 seasons from 2016 to The position with the highest number of injuries was striker,
2019 (there was no record from the CBF second division in followed by wings. The positions with the lowest number of
2019), totaling 3,828 matches and 126,357 match hours. ankle injuries were goalkeepers and defenders (►Table 1).
Regarding the total number of injured players from the same
position, ankle sprains were more prevalent in midfielders
Results
(►Table 3).
During the study, there were 7,899 on-pitch care visits, of The midfield had the highest number of sprains (75.50%).
which 2,486 resulted in the diagnosis of injuries. Of these, Only 13.04% of injuries occurred in the defense area, and
253 ankle sprains were recorded (10.17% of total injuries) 11.46% in the attack area (►Table 1). The player’s position
with a FIFA index equal to 2,002. Over the years, the total was statistically associated with the place on the pitch where
number of injuries progressively dropped from 86 in 2016 to the injury occurred (p < 0.001), with the defensive midfield
38 in 2019. being the most common place for sprains for all positions,
except for strikers (who presented more sprains in the attack
Diagnoses, Age, and Supplementary Tests area) and goalkeepers (who presented more sprains in the
We identified six different diagnoses of ankle sprain injuries defensive area). The end of each half-time had the highest
during the championships. The most common injuries were number of injuries, and 47.04% of lesions occurred between
lateral ligament lesions (LLLs), which represented 53.75% of 31 and 45 minutes and 75 and 90 minutes (►Table 4).

Table 2 Imaging tests requested for each injury diagnosis

Diagnosis None MRI X-ray X-ray þ MRI X-ray þ MRI þ CT Total

Simple sprain 15 9 48 1 0 73
Unimalleolar ankle fracture 0 0 2 0 0 2
Bimalleolar ankle fracture 0 0 8 0 0 8
Lateral ligament lesion 0 8 0 127 1 136
Medial ligament lesion 0 4 0 22 0 26
Syndesmosis injury 0 3 4 1 0 8
Total 15 24 62 151 1 253

Abbreviations: MRI, magnetic resonance imaging; X-ray, radiography; CT, computed tomography.

Table 3 Position of players with ankle injuries

Diagnosis Position
Striker Midfielder Defensive midfielder Wing Defender Goalkeeper
Simple sprain 25 (9.88%) 12 (4.74%) 6 (2.37%) 16 (6.32%) 8 (3.16%) 6 (2.37%)
Bimalleolar ankle fracture 0 1 (0.40%) 6 (5.61%) 0 1 (0.40%) 0
Unimalleolar ankle fracture 2 (0.79%) 1 (0.40%) 0 3 (1.19%) 1 (0.40%) 0
Lateral ligament lesion 46 (18.18%) 21 (8.30%) 0 26 (10.28%) 16 (6.32%) 3 (1.19%)
Medial ligament lesion 11 (4.35%) 3 (1.19%) 0 3 (1.19%) 4 (1.58%) 1 (0.40%)
Syndesmosis injury 2 (0.79%) 1 (0.40%) 5 (1.98%) 2 (0.79%) 0 0

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Table 4 Relationship between match time at injury occurrence and player position. Min, Minutes.

Position Match time

0–15 min 16–30 min 31–45 min 1st extra time 46–60 min 61–75 min 76–90 min 2nd extra time
Striker 4 (1.58%) 14 (5.53%) 20 (7.91%) 10 (3.95%) 4 (1.58%) 10 (3.95%) 22 (8.70%) 2 (0.79%)
Midfielder 6 (2.37%) 8 (3.16%) 9 (3.56%) 1 (0.40%) 3 (1.19%) 6 (2.37%) 9 (3.56%) 0
Defensive 2 (0.79%) 5 (1.98%) 6 (2.37%) 0 6 (2.37%) 1 (0.40%) 12 (4.74%) 0
midfielder
Wing 5 (1.98%) 6 (2.37%) 16 (6.32%) 5 (1.98%) 4 (1.58%) 4 (1.58%) 9 (3.56%) 1 (0.40%)
Defended 4 (1.58%) 2 (0.79%) 5 (1.98%) 3 (1.19%) 3 (1.19%) 8 (3.16%) 5 (1.98%) 0
Goalkeeper 1 (0.40%) 1 (0.40%) 1 (0.40%) 1 (0.40%) 1 (0.40%) 0 5 (1.98%) 0
Total 22 (8.70%) 36 (14.23%) 57 (22.53%) 20 (7.91%) 21 (8.30%) 25 (9.88% 62 (24.51%) 3 (1.19%

Table 5 Severity of ankle injuries

Diagnosis Severity
Mild Minor Moderate Major Severe
Simple sprain 38 (15.02%) 15 (5.93%) 20 (7.91%) 0 0
Bimalleolar ankle fracture 0 0 0 0 2 (0.79%)
Unimalleolar ankle fracture 0 1 (0.40%) 0 1 (0.40%) 6 (2.37%)
Lateral ligament lesion 32 (12.65%) 44 (17.39%) 55 (21.74%) 4 (1.58) 1 (0.40%)
Medial ligament lesion 4 (1.58%) 10 (3.95%) 0 1 (0.40%) 1 (0.40%)
Syndesmosis injury 0 0 3 (1.19%) 4 (1.58%) 1 (0.40%)
Total 74 (29.25%) 70 (27.67%) 78 (30.83%) 10 (3.95%) 11 (4.35%)

Recurrence, Surgery, and Time Away from Ekstrand et al.4 stated that ankle sprains accounted for 17 to
Competitions 21% of all sports injuries, showing their great representation.
Injuries recurred in 31.22% of cases. Simple sprains (38.36%) Our study identified a FIFA index of 2.00 for ankle sprains, a
and LLLs (32.35%) had the highest recurrence rates, while value higher than upper limb injuries (FIFA index ¼ 1.34)5 and
fractures did not recur (►Table 1). ruptures of the anterior cruciate ligament (FIFA index ¼ 0.41),6
Injuries underwent surgical treatment in 7.11% of cases. but lower than muscle injuries (FIFA index ¼ 7.66).7
Unimalleolar ankle fractures represented 33.33% of surger- A German study with Bundesliga (the German profession-
ies. No simple ankle sprain received surgical treatment, and al football league) athletes observed 280 episodes of ankle
only 3.68% of LLLs and 7.69% of LLMs required surgery. sprains (5.17% of total injuries) from the 2008 to 2014
Recurrent injuries were treated surgically in 12.65% of cases, seasons. This study reported a rate of 46.66 injuries per
in contrast to 80% of non-recurrent injuries (►Table 1). year, which represents a difference of 35.55% concerning our
Injuries were classified per severity according to the study.3 Árnason et al.8 evaluated 10 elite Icelandic football
athlete’s absence time, as follows: mild (< 3 days), minor clubs, and 82% of the injuries occurred in the lower limbs.
(3–7 days), moderate (8–28 days), major (4–8 weeks), and Dauty et al.9 found no difference in the incidence of
severe (> 8 weeks) injuries. The average time off competi- injuries during the 15 seasons analyzed between 1995 and
tion was 13.95 days, with severe and major injuries ac- 2010, contrasting with our results. There is no reported
counting for 4.34% and 3.56% of total injuries, respectively reason for the lower number of injuries in our study. How-
(►Table 5). ever, over the years, the quality of prematch physical prepa-
ration, physical therapy, pitch quality, and injury prevention
treatments significantly improved in Brazilian football, po-
Discussion
tentially contributing to a reduction in injuries.2,10
The main findings of the present study were the high Evaluating the distribution of injuries by month, Kofotolis
incidence of ankle sprains over 4 years. Furthermore, sprains et al.11 observed that 47.48% of ankle sprains happened in
mainly affected strikers and midfielders, with higher occur- August and September. Morgan and Oberlander12 observed
rence in midfield and the final 15 minutes of each half-time. that 24% of lesions occurred in the first third of the season,
The recurrence rate was high (31.22%), and the average time 25% in the second third, and 29% in the last third of the
away from competitions was around 2 weeks. season, which also conflicts with our data.

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For Nery et al.,13 medial and lateral ligament injuries were mild, 26% were moderate, and 14% were severe.
represented 66.8% of the total number of ankle injuries Árnason et al.8 classified injuries into 4 categories according
during the 2 seasons evaluated. Compared with our study, to the time away from competition, and most athletes
63.93% of all ankle injuries were medial and lateral complex returned to the sport in less than 2 weeks. Cohen et al.2
lesions, consistent with the statement that medial and lateral observed that sprains resulted in absence for less than
complex injuries are common in ankle sprains. 7 days in 49.7% of cases, from 7 to 30 days in 45%, and
Árnason et al.8 noted that 29% of injuries resulted from over 30 days in 5.2% of cases. All these latter injuries
muscle lesions, 22% from ligament lesions, and 20% from underwent surgical treatment.
direct blunt trauma. Most ankle injuries presented lateral The main limitation of this study is the potential data
ankle complex lesions. collection bias inherent to epidemiological studies since club
In a systematic review of all ankle injuries in football, doctors were responsible for filling in the data on the
76.8% were ankle sprains, which is the most common cause platform. During this period, there were some changes of
of ankle injuries, consistent with our study.4 Nery et al.13 doctors in clubs. To reduce data collection bias, all doctors
indicated that the most common mechanism of trauma in received training to complete the survey. We were aware of
professional football athletes was direct player-to-player all club doctors’ replacements and trained the new doctors.
trauma (32%), with excessive use (intense joint mobility at Another limitation is the lack of consensus on the definition
the extreme of the range of motion) associated with 26% of of injury in the literature, hindering the comparison of our
the causes of ankle injuries. Kofotolis et al.11 also stated that results with those of other studies. Furthermore, we did not
most ankle injuries occurred through direct contact with collect data from injuries occurring during training sessions.
another athlete, with a 63.3% rate, while 36.7% of lesions did Lastly, the failure to evaluate the pitch quality and their
not result from contact. At the 2014 World Cup, 64.4% of relationship with sprains was another limitation of the study.
athletes’ injuries were due to contact.14 Despite these limitations, this is an extensive prospective
Striker was the athlete’s position on the pitch with most study lasting 4 years and with a large sample of athletes and
ankle sprains. However, considering midfielders and defen- injuries which collected unprecedented data from two major
sive midfielders together, the rate of simple sprains is higher professional football championships in Brazil.
(7.11%). Cohen et al.2 compared athletes’ total body injuries
and observed that the midfield position had the highest
Conclusion
number of injuries Leventer et al.15 and Morgan and Ober-
lander12 showed that midfielders had 37.6% of total body Ankle sprains are common injuries in football. Although the
injuries in the Major League of Soccer (MLS). average time to return to sport is brief, these injuries have a
Dauty et al.9 found no difference in the number of any high recurrence rate and are potentially surgical, leading to a
injury type regarding pitch positions; however, there was a longer time away from competitions. The most common
slight tendency towards defenders. Kofotolis et al. observed injuries were LLLs and simple sprains. The most affected
more injuries in defenders and wings (42.4%) compared to positions were striker and midfielder, with higher occurrence
midfielders (32.3%) and strikers (20.8%).11 in the midfield and the final 15 minutes of each half-time.
Kofotolis et al.11 analyzed that 61.1% of ankle injuries
occurred in the final 15 minutes of both half-times, agreeing Authors’ Contribution
with our data. Hawkins et al.16 observed this same pattern. All authors contributed to the conception and design of
In the present study, 31.22% of injuries were recurrent. the study. EBSL and PHSL prepared the material prepara-
Árnason et al.8 observed that 35% of injuries were recurrent, tion, collected data, and performed the analysis. GGA and
with 8% occurring less than 1 month after the previous lesion. MC coordinated the research. EBSL, GMS, and EPM wrote
Kofotolis et al. found that 60.5% of athletes had recurrent the first version of the manuscript. All authors participat-
injuries.11 Football players with a history of previous ankle ed in writing the final manuscript and approved it for
sprains are 4.9 times more likely to have a recurrent lesion.13 submission.
Cohen et al.2 evaluated episodes of sprain, with 5.2%
(n ¼ 9) of the cases progressing to some surgical procedure Financial Support
from a total of 173 cases. According to Nery et al.,13 20% of The authors declare that they did not receive any financial
athletes with acute ankle sprains will develop mechanical or support from public, commercial, or not-for-profit sources.
functional ankle instability, resulting in chronic ankle insta-
bility and requiring surgical treatment. Conflict of Interests
Kofotolis et al.11 also evaluated the time away from com- The authors have no conflict of interests to declare.
petitions. These authors noted that simple sprains represented
the most common injury with less than seven missed sessions. Acknowledgments
Injury to the anterior tibiotalar ligament resulted in the highest We thank all club doctors for their contributions to data
absence rate and 58.7% of total time lost due to lesion. collection and the Brazilian Football Confederation (CBF)
Morgan and Oberlander12 classified the severity of the and the Paulista Football Federation (FPF) for supporting
injury into three categories. Of the 256 injuries found, 60% this research.

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