Injury patterns in the Korean Women’s Professional Football League during the COVID- 19 season: A prospective epidemiological study

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However, prospective epidemiological data on East Asian female players remain scarce, especially during atypical seasons such as the COVID-19 pandemic. This study aimed to characterise the injury patterns in the Korean Women’s Professional Football League (WKFL) during the 2020 pandemic season, with a focus on injury location, type, mechanism, severity and positional distribution. Methods A prospective cohort study was conducted involving 138 elite female athletes from six WKFL teams during the 2020 season. Injury and exposure data were systematically collected after each training session and match using standardised injury surveillance forms. The team coaching staff submitted weekly reports. Injury incidence rates were calculated per 1,000 h of exposure and categorised by injury location, type, mechanism, context (training vs. match) and player position. Results During a total exposure time of 22,523 h, 132 injuries were reported. The overall injury incidence rate was 5.86 per 1,000 h (95% confidence interval, 4.86–6.86). The match injury rate was 11.5 times higher than the training injury rate. The majority of injuries affected the lower extremities (81.8%), with the ankle (25.0%), knee (22.7%) and thigh (15.9%) being the most commonly injured sites. Muscle injuries were more prevalent during training sessions, likely due to extended exposure time and insufficient conditioning. Knee injuries were primarily noncontact and recurrent, observed across all field positions. Defenders exhibited the highest rates of thigh, ankle and foot/toe injuries, whereas midfielders were more susceptible to lower leg and Achilles tendon injuries, predominantly caused by overuse mechanisms. Conclusions This first prospective analysis of injury patterns in the WKFL reveals a predominance of lower extremity injuries and distinct differences in injury profiles between training and match contexts. The COVID-19 pandemic may have exacerbated training-related muscle injuries due to schedule disruptions and inadequate conditioning. The observed position-specific injury trends underscore the importance of tailored injury prevention strategies aligned with the physical demands of each playing role. Longitudinal studies are warranted to guide effective injury mitigation in elite women’s football. ankle injury COVID-19 injury prevention muscle injury sports injury women’s football Figures Figure 1 Background Women’s football has witnessed exponential global growth over the past decade, with participation numbers nearly quadrupling since 2019 to reach 16.6 million, including 3.9 million players registered with national football associations. 1 In response, the Fédération Internationale de Football Association (FIFA) has launched key initiatives, including the 2018 Women’s Football Strategy, which aims to increase global participation to 60 million by 2026, 2 and the 2023 Female Health Project, which focuses on optimising female athlete performance and enhancing injury prevention efforts. 3 Similar growth has occurred in South Korea, where the number of elite players has surpassed 1,500 across 67 teams, accompanied by a fourfold to fivefold increase in registered amateur players. 4 However, this rapid expansion has been paralleled by a notable rise in injury rates, which adversely impact athletes physically, psychologically and financially, ultimately influencing both individual and team performance. A recent meta-analysis of 22 studies estimated the injury incidence in elite women’s football at 6.1 injuries per 1,000 h of exposure. 5 As participation increases, there is a growing need to understand injury patterns and risk factors to inform effective prevention strategies. However, most epidemiological studies in women’s football have been conducted in Western populations, limiting the applicability of findings to East Asian athletes. Although injury surveillance is essential for guiding prevention efforts, 6 prospective epidemiological studies on female football players in East Asia, particularly in South Korea, remain limited. Existing studies have primarily employed retrospective designs 7 or focused on short-term national team analyses, 8 failing to provide season-long data from professional league contexts. Thus, comprehensive, prospective research that includes both national and non-national players within professional leagues is necessary to develop targeted and culturally relevant injury prevention strategies. The coronavirus disease 2019 (COVID-19) pandemic further complicated injury risk and management by disrupting training and competition schedules and increasing both mental and physical stress among athletes. 9 – 11 Several investigations in Europe and North America have examined the impact of COVID-19 lockdowns on elite football. 12 – 14 For instance, overall injury incidence in North American professional men’s soccer more than doubled during the pandemic period, 14 whereas a study of Spanish women’s professional soccer reported no significant association between COVID-19 infection and the incidence of noncontact muscle injuries. 13 Nonetheless, the majority of these studies have focused on male athletes or have addressed only limited dimensions, such as GPS-based workload metrics or aggregate injury rates. To date, no study has examined the influence of the COVID-19 pandemic on injury patterns in the Korean Women’s Professional Football League (WKFL). Accordingly, this prospective study aimed to characterise the epidemiology of injuries in the WKFL during the 2020 COVID-19-affected season. Specifically, the objectives were (a) to quantify injury incidence rates based on actual exposure time, (b) to describe the distribution of injuries sustained during matches and training sessions by injury location, type, severity and mechanism and (3) to summarise the characteristics of the most frequent injuries, including recurrence status, player position and field location at the time of injury. Methods Study design This prospective cohort study investigated injury incidence and characteristics among six of the eight elite women’s football teams competing in the 2020 WKFL season. Two teams withdrew and were excluded. Data were collected from April to November 2020, encompassing both the pre-season (April) and the official season (May to November). Participants This study was approved by the Institutional Review Board of Yonsei University (IRB No. 7001988-202005-HR-887-03) and was conducted in accordance with the principles of the Declaration of Helsinki. A total of 138 elite female athletes registered in the WKFL participated in the study. Written informed consent was obtained from all participants following a full explanation of the study. Baseline demographic and clinical information—including height, weight, playing position, leg dominance, career duration and history of knee or ankle injuries—was collected during the initial screening. Data collection and procedures Injury surveillance was conducted throughout the 2020 WKFL season. Reports were submitted weekly by each team’s coaching staff, documenting injuries sustained during matches and training sessions. These reports included details such as the date, anatomical location, injury type, mechanism, severity, recurrence and playing position. Diagnoses were confirmed by a team physician or a licensed medical professional. The reporting format was based on the consensus statements of FIFA’s Medical Assessment and Research Centre and the International Olympic Committee’s Injury Surveillance System. 15 , 16 Injury definition and classification In accordance with international consensus for football injury research, an injury was defined as any musculoskeletal complaint sustained during a match or training session, regardless of the need for medical attention or time loss. 15 , 16 Injury location Injury location was categorised into three anatomical regions: head and trunk, upper extremities and lower extremities. The head and trunk category encompasses the head/face, cervical spine/sternum/ribs/upper back, abdomen and lower back/pelvis/sacrum. The upper extremities category includes the shoulder/clavicle, upper arm, elbow, forearm and wrist/hand/finger/thumb. The lower extremities category includes the hip/groin, thigh, knee, lower leg/Achilles tendon, ankle and foot/toe. Injury type Injury types were classified as follows: bone (fractures and other bony injuries), joint and ligament (dislocation/subluxation, sprain/ligamentous injury, meniscus/cartilage lesions), muscle and tendon (muscle rupture/strain/tear, tendon injury, bursitis), neurological (concussion) and others (hematoma, contusion or bruise). Injury mechanism Injury mechanism categories included contact (with another person, playing surface, ball, equipment, or external object), noncontact and overuse or chronic mechanisms. Injury severity Injury severity was classified by time-loss duration as follows: slight ( 28 days). 15 Data management and statistical analysis Clinical incidence was calculated as the number of injuries sustained during matches divided by the total number of participating athletes. The injury incidence rate was calculated based on each athlete’s exposure time during matches or training sessions. 17 To standardise the rates, we computed the injury incidence rate per 1,000 h of exposure (IIR HE ). Injury rates were analysed separately for matches and training and 95% confidence intervals (95% CIs) were calculated for all injury rate estimates. 17 To compare injury incidence rate ratios ( RR s) between matches and training sessions, we calculated the RR s and corresponding 95% CIs by injury location, type and mechanism. Data management and statistical analyses were performed using Microsoft Excel (Microsoft Corp., Redmond, Washington) and MedCalc version 22.021 (MedCalc, Mariakerke, Belgium). Results A total of 138 athletes from six of the eight teams participated in the study (mean height: 166.2 ± 4.8 cm, mean weight: 58.7 ± 5.8 kg, mean playing career: 13.54 ± 3.76 yr; Table 1). Exposure and injuries During the 2020 WKFL season, a total of 132 injuries were recorded—68 during matches (51.52%) and 64 during training (48.48%). Detailed exposure and injury incidence data are presented in Table 1. Total athlete exposure time was 22,523 h, comprising 1,905 match hours and 20,618 training hours. The overall injury incidence per 100 registered athletes was 95.65 (95% CI, 79.33–111.97), with match and training incidence rates of 49.28 (95% CI, 37.56–60.99) and 46.38 (95% CI, 35.01–57.74), respectively. The overall IIR HE was 5.86 (95% CI, 4.86–6.86), with match and training rates of 35.70 (95% CI, 27.21–44.18) and 3.10 (95% CI, 2.34–3.86), respectively. The injury rate during matches was 11.50 times higher than during training (95% CI, 8.15–16.23). Injury characteristics: Location, type, mechanism and severity The most frequently injured body part was the ankle ( n = 33, 25.0%), followed by the knee ( n = 30, 22.7%), thigh ( n = 21, 15.9%), lower leg/Achilles tendon ( n = 12, 9.1%) and foot/toe ( n = 12, 9.1%; Table 2). Lower back/pelvis/sacrum injuries were the next most common ( n = 10, 7.6%), followed by injuries to the head/face ( n = 5, 3.8%). Head/face injuries were more prevalent during matches than training ( RR = 10.36), while knee injuries occurred more frequently during training than matches ( RR = 0.47). Sprain/ligamentous injury was the most common injury type ( n = 41, 31.1%), followed by muscle rupture/strain/tear ( n = 30, 22.7%), meniscus/cartilage lesions ( n = 19, 14.4%), hematoma/contusion/bruise ( n = 11, 8.3%), fracture ( n = 10, 7.6%) and tendon injury/bursitis ( n = 10, 7.6%). The most frequent injury mechanism was noncontact ( n = 36, 27.3%), followed by contact with another person ( n = 35, 26.5%), overuse/chronic ( n = 27, 20.5%), contact with the playing surface ( n = 17, 12.9%) and contact with the ball ( n = 9, 6.8%; Table 2). Injury severity distribution is shown in Figure 1. Among the 132 injuries, 19 involved the head and trunk—mild and moderate injuries each accounted for 31.6%, minimal injuries for 21.1% and severe injuries for 15.8%. Of the five upper extremity injuries, three were mild and two were severe. Lower extremity injuries accounted for 108 of the total 132 injuries. Among these, severe injuries were most frequent (44.4%), followed by moderate (29.6%), mild (13.0%), minimal (8.3%) and slight (4.6%) injuries. Most frequent injuries Table 3 presents a detailed analysis of the five most common injury sites. Ankle sprain/ligamentous injuries were the most frequent, commonly associated with a history of previous ankle injuries (33.3%), severe classification (45.5%) and defender positions (57.6%). Knee injuries ranked second, often related to prior knee injuries (40.0%), meniscus/cartilage lesions (53.3%), noncontact mechanisms (43.3%), severe severity (56.7%) and striker positions (33.3%). Thigh injuries ranked third and were primarily muscle ruptures/strains/tears (85.7%), with overuse/chronic (42.9%) and noncontact (38.1%) mechanisms; most were moderate in severity (38.1%). Lower leg/Achilles tendon injuries ( n = 12) were frequently due to muscle rupture/strain/tear (41.7%) and overuse/chronic mechanisms (58.3%), with most classified as severe (58.3%). Foot/toe injuries ( n = 12) comprised various types, were generally severe and involved contact mechanisms more frequently than knee and thigh injuries. Discussion This study investigated injury patterns during the 2020 season of the WKFL, which was notably affected by the COVID-19 pandemic. The analysis focused on injury incidence relative to exposure time and examined the distribution of injuries by anatomical location, type, severity, mechanism and player position. Although the primary objective was to describe injury characteristics during this specific season, it is important to acknowledge that pandemic-related disruptions, such as altered training routines, condensed match schedules and limited conditioning, likely influenced the injury landscape. These contextual factors should be considered when comparing our findings with those of prior studies. The overall injury incidence was 5.86 per 1,000 h of exposure (95% CI, 4.86–6.86), with match injuries occurring at a rate 11.50 times higher than those during training (95% CI, 8.15–16.23). While baseline data from pre-pandemic WKFL seasons are unavailable, similar studies conducted during the pandemic have reported varying trends. For instance, research in UEFA men’s professional football reported no significant change in match injury incidence following the lockdown, 18 whereas studies of elite UEFA women’s clubs found lower match injury rates during the pandemic-affected season than previous years. 19 These discrepancies suggest that injury patterns may differ based on sex, league structure and competitive context. Lower extremity injuries were the most prevalent, aligning with findings from European women’s leagues. 19 Notably, knee injuries were more frequently observed during training, while thigh and foot/toe injuries predominated in matches. These differences likely reflect the divergent physical demands of training and competition. Match play is characterised by high-intensity and aggressive physical engagement, which may lead to more acute injuries. In contrast, training sessions often involve repetitive movements, contributing to the development of overuse injuries. 20 This pattern suggests that WKFL players may be particularly susceptible to knee overuse injuries during training, possibly due to repetitive loading and insufficient recovery. Although muscle injuries are generally more common during matches due to higher physical demands, 21 , 22 our findings revealed a higher incidence of muscle injuries during training. This observation is consistent with a 5-yr study on the Korean women’s national team 8 and may be attributed to the disproportionate exposure time—20,618 h in training versus only 1,905 h in matches. This training-to-match exposure ratio was substantially higher than those reported in elite leagues in Kosovo (training: 22,375 h; match: 3,748 h) 23 and Spain (training: 21,850 h; match: 3,544 h). 24 The elevated training volume, combined with insufficient physical conditioning and cumulative fatigue, may have contributed to the observed injury trends. 8 – 25 Moreover, pandemic-related changes likely exacerbated these issues. Supporting evidence from the German Bundesliga indicated an increase in muscle injuries post-lockdown, attributed to deconditioning and congested match schedules. 26 Disruptions to regular training programmes may have further compromised players’ physical readiness. 27 These findings underscore the necessity of structured training regimens and appropriate load management to reduce the risk of both muscle and noncontact injuries. In contrast, fracture and contusion injuries (hematoma/contusion/bruise) were more common during matches. These injury types typically result from direct impact and high-intensity collisions that are characteristic of competitive match play. 28 – 30 Given these environmental demands, implementing injury surveillance systems and optimising training loads are critical steps towards injury prevention. Future research should investigate athletes’ perceptions of fatigue and workload and assess specific training environments that may predispose players to injury. Regarding injury mechanisms, contact-related injuries were more frequently reported in matches, with contact with another player occurring 3.76 times more often than in training. This is consistent with the higher physical intensity of match play, especially during tournaments with condensed schedules. 30 , 31 Conversely, noncontact and overuse injuries predominated in training sessions. A similar trend was reported in Saudi Arabian football post-lockdown, with an increase in noncontact injuries likely resulting from deconditioning. 27 As noncontact injuries are more common among female athletes, preventative strategies such as neuromuscular training programmes are crucial. 32 Head and facial injuries during matches occurred at a rate 10.36 times higher than during training. Although only one concussion was recorded in this study, head injuries remain a significant concern due to their potential severity. Bundesliga data during the COVID-19 period reported a reduction in head injuries, possibly due to fewer contact duels under modified competition protocols. 33 These findings suggest that policy changes may influence injury profiles, although causality has yet to be established. Notably, female athletes have been reported to experience higher concussion rates than their male counterparts. 34 , 35 This disparity may be due to increased symptom reporting 19 , 36 or physiological factors such as reduced neck strength. 37 Given the possibility of underreporting or underrecognition of concussions among female footballers, it is essential to provide education on concussion symptoms and management to both players and coaching staff. Our findings also revealed position-specific injury patterns. Defenders experienced the highest number of thigh muscle injuries, most of which were noncontact or overuse-related. These injuries often occur during high-intensity actions such as sprinting, sudden directional changes and kicking. 25 Interestingly, while these movements are typically associated with forwards, 38 defenders in our study were most affected. Similarly, a COVID-19 study in the Bundesliga found that muscle injuries were most prevalent among defenders, especially fullbacks. 26 Additionally, ankle and foot/toe injuries—typically caused by contact—were also common among defenders, likely due to their involvement in tackling, blocking and intercepting. 39 – 41 Midfielders, whose role demands continuous running and endurance, 39 were most frequently affected by lower leg and Achilles tendon injuries, which were predominantly noncontact or overuse in nature. The high physical load associated with the midfielder role likely contributes to the development of these injuries. In contrast, knee injuries—known for their high severity and recurrence—were observed across all outfield positions except goalkeepers. Most knee injuries were attributed to noncontact mechanisms, such as pivoting, jumping and landing, which are inherent to football. Anterior cruciate ligament ruptures remain a significant concern in female athletes, given their higher prevalence in this population. 24 , 42 These position-specific injury trends emphasize the need for tailored prevention strategies in the WKFL. Training and conditioning programmes should be designed to address the biomechanical and workload demands of each playing position, particularly with a focus on reducing noncontact injury risk. Further studies should aim to develop and evaluate targeted interventions that are aligned with the injury profiles of specific field positions. Limitations This study is the first to investigate injury patterns in the WKFL during the COVID-19-impacted 2020 season; however, several limitations should be acknowledged. First, the analysis was limited to a single season, which restricts the ability to assess injury trends across pre-pandemic and post-pandemic periods and limits causal inferences. Second, the study did not include data on players’ COVID-19 infection status or their physiological responses to exercise during lockdown, which may have influenced injury susceptibility. Lastly, although the study included 138 athletes from six of the eight league teams, the relatively small sample size and partial team participation may affect the generalizability of the findings. Conclusions Injuries during the 2020 pandemic season in women’s football occurred more frequently during matches and primarily affected the lower extremities. Injury patterns varied depending on activity type (match vs. training) and player position. Notably, muscle injuries, which are typically more prevalent during competition, were more frequently observed during training. This trend is likely attributable to increased training exposure and inadequate conditioning, exacerbated by the disruptions caused by the pandemic. The COVID-19 crisis introduced significant challenges, including prolonged periods of deconditioning and altered training regimens, both of which may have heightened the risk of injury. To gain a more comprehensive understanding of injury trends, future studies should incorporate extended surveillance across multiple seasons. Additionally, in-depth analyses of training environments and workloads will be essential to inform injury prevention strategies and safeguard athlete health and performance. Abbreviations 95% CI 95% confidence interval COVID-19 coronavirus disease 2019 FIFA Fédération Internationale de Football Association RR rate ratio WKFL Korean Women’s Professional Football League Declarations Ethical approval and consent to participate This study was approved by the Ethics Committee of Yonsei University. Consent for publication Not required. Availability of data and materials The data from this study are available from the corresponding author upon request. Competing interests The authors declare no competing interests. Funding This research did not receive any funding from external sources. Authors’ Contributions Jae Min Lee : Conceptualisation, Data Curation, Formal Analysis, Investigation, Writing—Original Draft. Suji Yoon : Conceptualisation, Data Curation, Formal Analysis, Writing—Original Draft. Hyung Gyu Jeon : Conceptualisation, Data Curation, Formal Analysis, Writing—Review and Editing. Seon Hee Im : Project Administration, Conceptualisation, Data Curation, Formal Analysis, Investigation, Writing—Review and Editing. Sae Yong Lee : Project Administration, Conceptualisation, Data Curation, Formal Analysis, Writing—Review and Editing. Acknowledgements This study was conducted in collaboration with the Korean Women’s Professional Soccer League. The authors sincerely thank all participating players and team physicians for their invaluable support. 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Bretzin AC, Mansell JL, Tierney RT, McDevitt JK. Sex differences in anthropometrics and heading kinematics among division I soccer athletes: a pilot study. Sports Health. 2017;9:168–73. Dauty M, Collon S. Incidence of injuries in French professional soccer players. Int J Sports Med. 2011;32:965–9. Worrall H, Podvin C, Althoff C, Chung JS, Sugimoto D, Stokes M, et al. Position comparison of sport-related concussions in female youth soccer players. Phys Sportsmed. 2024;52:325–32. Giza E, Fuller C, Junge A, Dvorak J. Mechanisms of foot and ankle injuries in soccer. Am J Sports Med. 2003;31:550–4. Giza E, Micheli LJ. Soccer injuries. In: Maffulli N, Caine DJ, editors. Epidemiology of pediatric sports injuries: team sports. Basel: S. Karger AG; 2005. Hewett TE, Myer GD, Ford KR. Anterior cruciate ligament injuries in female athletes: Part 1, mechanisms and risk factors. Am J Sports Med. 2006;34:299–311. Tables Table 1 to 3 available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7120154","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":500119600,"identity":"0bd4537b-dda8-4851-8f25-abc3a1565d0f","order_by":0,"name":"Jae Min Lee","email":"","orcid":"","institution":"Miraebone Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jae","middleName":"Min","lastName":"Lee","suffix":""},{"id":500119601,"identity":"1236abe5-3398-4451-8d00-15ec290cbf60","order_by":1,"name":"Suji Yoon","email":"","orcid":"","institution":"Yonsei University","correspondingAuthor":false,"prefix":"","firstName":"Suji","middleName":"","lastName":"Yoon","suffix":""},{"id":500119602,"identity":"ffd1847d-7818-4930-b249-adf34765733c","order_by":2,"name":"Hyung Gyu Jeon","email":"","orcid":"","institution":"Yonsei University","correspondingAuthor":false,"prefix":"","firstName":"Hyung","middleName":"Gyu","lastName":"Jeon","suffix":""},{"id":500119603,"identity":"b05e2b45-227a-4cc2-b9f2-a286a8bf8c80","order_by":3,"name":"Seon Hee Im","email":"","orcid":"","institution":"Sejong Sports Orthopedic Hospital","correspondingAuthor":false,"prefix":"","firstName":"Seon","middleName":"Hee","lastName":"Im","suffix":""},{"id":500119604,"identity":"666a25ad-c6fb-49ec-9831-fc818ba87b19","order_by":4,"name":"Sae Yong Lee","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIiWNgGAWjYFAC5gYGBgMbCDsBRPAQ1MII1FKQRrKWD4eRBAhpkZ+R2Pjgg8H5xH7p9ocPHjDYyTPwnH2AV4vBjcRmwxkGtxNnzjljbJDAkGzYwNtugF+LRGKbNA9Qy4YbOWwSCQzMCQz8bAQd1v77j8E5oJb05z8SGOoJa2G4kdjGzGBwAKglwQwYYocTGHjb8OswOPOwWbLHINl45owcY4kEg+OGbTzHCDisPfnghx9/7GT7JdIffvxRUS3Pz5NGwGECCWDKsQFiKQMDIZ8wMPAfAFP2BBWOglEwCkbByAUALT9FU/dP3oYAAAAASUVORK5CYII=","orcid":"","institution":"Yonsei University","correspondingAuthor":true,"prefix":"","firstName":"Sae","middleName":"Yong","lastName":"Lee","suffix":""}],"badges":[],"createdAt":"2025-07-14 10:38:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7120154/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7120154/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89075311,"identity":"2c12ca90-e901-4bd9-94f1-ce6714d279ce","added_by":"auto","created_at":"2025-08-14 12:05:23","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":49156,"visible":true,"origin":"","legend":"\u003cp\u003eInjury severity distribution by body part\u003c/p\u003e","description":"","filename":"Figure1..jpg","url":"https://assets-eu.researchsquare.com/files/rs-7120154/v1/9f13c70d3d3b7464b5f2bfe2.jpg"},{"id":96276495,"identity":"d67ece0c-75d9-4aba-bf5e-639d6590cd4e","added_by":"auto","created_at":"2025-11-19 10:09:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":615319,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7120154/v1/d1987bf3-3a29-48d8-a718-1aadb74ab26c.pdf"},{"id":89074950,"identity":"7943115f-5c69-4d36-8850-250e885aff7f","added_by":"auto","created_at":"2025-08-14 11:57:23","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":130987,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-7120154/v1/3cc57eebd6605738424ae6dd.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Injury patterns in the Korean Women’s Professional Football League during the COVID- 19 season: A prospective epidemiological study","fulltext":[{"header":"Background","content":"\u003cp\u003eWomen’s football has witnessed exponential global growth over the past decade, with participation numbers nearly quadrupling since 2019 to reach 16.6\u0026nbsp;million, including 3.9\u0026nbsp;million players registered with national football associations.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e In response, the Fédération Internationale de Football Association (FIFA) has launched key initiatives, including the 2018 Women’s Football Strategy, which aims to increase global participation to 60\u0026nbsp;million by 2026,\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e and the 2023 Female Health Project, which focuses on optimising female athlete performance and enhancing injury prevention efforts.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Similar growth has occurred in South Korea, where the number of elite players has surpassed 1,500 across 67 teams, accompanied by a fourfold to fivefold increase in registered amateur players.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e However, this rapid expansion has been paralleled by a notable rise in injury rates, which adversely impact athletes physically, psychologically and financially, ultimately influencing both individual and team performance. A recent meta-analysis of 22 studies estimated the injury incidence in elite women’s football at 6.1 injuries per 1,000 h of exposure.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eAs participation increases, there is a growing need to understand injury patterns and risk factors to inform effective prevention strategies. However, most epidemiological studies in women’s football have been conducted in Western populations, limiting the applicability of findings to East Asian athletes. Although injury surveillance is essential for guiding prevention efforts,\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e prospective epidemiological studies on female football players in East Asia, particularly in South Korea, remain limited. Existing studies have primarily employed retrospective designs\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e or focused on short-term national team analyses,\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e failing to provide season-long data from professional league contexts. Thus, comprehensive, prospective research that includes both national and non-national players within professional leagues is necessary to develop targeted and culturally relevant injury prevention strategies.\u003c/p\u003e\u003cp\u003eThe coronavirus disease 2019 (COVID-19) pandemic further complicated injury risk and management by disrupting training and competition schedules and increasing both mental and physical stress among athletes.\u003csup\u003e\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e–\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Several investigations in Europe and North America have examined the impact of COVID-19 lockdowns on elite football.\u003csup\u003e\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e–\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e For instance, overall injury incidence in North American professional men’s soccer more than doubled during the pandemic period,\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e whereas a study of Spanish women’s professional soccer reported no significant association between COVID-19 infection and the incidence of noncontact muscle injuries.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Nonetheless, the majority of these studies have focused on male athletes or have addressed only limited dimensions, such as GPS-based workload metrics or aggregate injury rates. To date, no study has examined the influence of the COVID-19 pandemic on injury patterns in the Korean Women’s Professional Football League (WKFL).\u003c/p\u003e\u003cp\u003eAccordingly, this prospective study aimed to characterise the epidemiology of injuries in the WKFL during the 2020 COVID-19-affected season. Specifically, the objectives were (a) to quantify injury incidence rates based on actual exposure time, (b) to describe the distribution of injuries sustained during matches and training sessions by injury location, type, severity and mechanism and (3) to summarise the characteristics of the most frequent injuries, including recurrence status, player position and field location at the time of injury.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design\u003c/p\u003e\u003cp\u003eThis prospective cohort study investigated injury incidence and characteristics among six of the eight elite women’s football teams competing in the 2020 WKFL season. Two teams withdrew and were excluded. Data were collected from April to November 2020, encompassing both the pre-season (April) and the official season (May to November).\u003c/p\u003e\u003cp\u003eParticipants\u003c/p\u003e\u003cp\u003eThis study was approved by the Institutional Review Board of Yonsei University (IRB No. 7001988-202005-HR-887-03) and was conducted in accordance with the principles of the Declaration of Helsinki. A total of 138 elite female athletes registered in the WKFL participated in the study. Written informed consent was obtained from all participants following a full explanation of the study. Baseline demographic and clinical information—including height, weight, playing position, leg dominance, career duration and history of knee or ankle injuries—was collected during the initial screening.\u003c/p\u003e\u003cp\u003eData collection and procedures\u003c/p\u003e\u003cp\u003eInjury surveillance was conducted throughout the 2020 WKFL season. Reports were submitted weekly by each team’s coaching staff, documenting injuries sustained during matches and training sessions. These reports included details such as the date, anatomical location, injury type, mechanism, severity, recurrence and playing position. Diagnoses were confirmed by a team physician or a licensed medical professional.\u003c/p\u003e\u003cp\u003eThe reporting format was based on the consensus statements of FIFA’s Medical Assessment and Research Centre and the International Olympic Committee’s Injury Surveillance System.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eInjury definition and classification\u003c/p\u003e\u003cp\u003eIn accordance with international consensus for football injury research, an injury was defined as any musculoskeletal complaint sustained during a match or training session, regardless of the need for medical attention or time loss.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eInjury location\u003c/em\u003e\u003c/p\u003e\u003cp\u003eInjury location was categorised into three anatomical regions: head and trunk, upper extremities and lower extremities. The head and trunk category encompasses the head/face, cervical spine/sternum/ribs/upper back, abdomen and lower back/pelvis/sacrum. The upper extremities category includes the shoulder/clavicle, upper arm, elbow, forearm and wrist/hand/finger/thumb. The lower extremities category includes the hip/groin, thigh, knee, lower leg/Achilles tendon, ankle and foot/toe.\u003c/p\u003e\u003cp\u003e\u003cem\u003eInjury type\u003c/em\u003e\u003c/p\u003e\u003cp\u003eInjury types were classified as follows: bone (fractures and other bony injuries), joint and ligament (dislocation/subluxation, sprain/ligamentous injury, meniscus/cartilage lesions), muscle and tendon (muscle rupture/strain/tear, tendon injury, bursitis), neurological (concussion) and others (hematoma, contusion or bruise).\u003c/p\u003e\u003cp\u003e\u003cem\u003eInjury mechanism\u003c/em\u003e\u003c/p\u003e\u003cp\u003eInjury mechanism categories included contact (with another person, playing surface, ball, equipment, or external object), noncontact and overuse or chronic mechanisms.\u003c/p\u003e\u003cp\u003e\u003cem\u003eInjury severity\u003c/em\u003e\u003c/p\u003e\u003cp\u003eInjury severity was classified by time-loss duration as follows: slight (\u0026lt; 1 day), minimal (1–3 days), mild (4–7 days), moderate (8–28 days) or severe (\u0026gt; 28 days).\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eData management and statistical analysis\u003c/p\u003e\u003cp\u003eClinical incidence was calculated as the number of injuries sustained during matches divided by the total number of participating athletes. The injury incidence rate was calculated based on each athlete’s exposure time during matches or training sessions.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e To standardise the rates, we computed the injury incidence rate per 1,000 h of exposure (IIR\u003csub\u003eHE\u003c/sub\u003e). Injury rates were analysed separately for matches and training and 95% confidence intervals (95% CIs) were calculated for all injury rate estimates.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e To compare injury incidence rate ratios (\u003cem\u003eRR\u003c/em\u003es) between matches and training sessions, we calculated the \u003cem\u003eRR\u003c/em\u003es and corresponding 95% CIs by injury location, type and mechanism. Data management and statistical analyses were performed using Microsoft Excel (Microsoft Corp., Redmond, Washington) and MedCalc version 22.021 (MedCalc, Mariakerke, Belgium).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 138 athletes from six of the eight teams participated in the study (mean height: 166.2 \u0026plusmn; 4.8 cm, mean weight: 58.7 \u0026plusmn; 5.8 kg, mean playing career: 13.54 \u0026plusmn; 3.76 yr; Table 1).\u003c/p\u003e\n\u003ch2\u003eExposure and injuries\u003c/h2\u003e\n\u003cp\u003eDuring the 2020 WKFL season, a total of 132 injuries were recorded\u0026mdash;68 during matches (51.52%) and 64 during training (48.48%). Detailed exposure and injury incidence data are presented in Table 1. Total athlete exposure time was 22,523\u0026nbsp;h, comprising 1,905 match hours and 20,618 training hours.\u003c/p\u003e\n\u003cp\u003eThe overall injury incidence per 100 registered athletes was 95.65 (95% CI, 79.33\u0026ndash;111.97), with match and training incidence rates of 49.28 (95% CI, 37.56\u0026ndash;60.99) and 46.38 (95% CI, 35.01\u0026ndash;57.74), respectively. The overall IIR\u003csub\u003eHE\u003c/sub\u003e was 5.86 (95% CI, 4.86\u0026ndash;6.86), with match and training rates of 35.70 (95% CI, 27.21\u0026ndash;44.18) and 3.10 (95% CI, 2.34\u0026ndash;3.86), respectively. The injury rate during matches was 11.50 times higher than during training (95% CI, 8.15\u0026ndash;16.23).\u003c/p\u003e\n\u003ch2\u003eInjury characteristics: Location, type, mechanism and severity\u003c/h2\u003e\n\u003cp\u003eThe most frequently injured body part was the ankle (\u003cem\u003en\u003c/em\u003e = 33, 25.0%), followed by the knee (\u003cem\u003en\u003c/em\u003e = 30, 22.7%), thigh (\u003cem\u003en\u003c/em\u003e = 21, 15.9%), lower leg/Achilles tendon (\u003cem\u003en\u003c/em\u003e = 12, 9.1%) and foot/toe (\u003cem\u003en\u003c/em\u003e = 12, 9.1%; Table 2). Lower back/pelvis/sacrum injuries were the next most common (\u003cem\u003en\u003c/em\u003e = 10, 7.6%), followed by injuries to the head/face (\u003cem\u003en\u003c/em\u003e = 5, 3.8%). Head/face injuries were more prevalent during matches than training (\u003cem\u003eRR\u003c/em\u003e = 10.36), while knee injuries occurred more frequently during training than matches (\u003cem\u003eRR\u003c/em\u003e = 0.47).\u003c/p\u003e\n\u003cp\u003eSprain/ligamentous injury was the most common injury type (\u003cem\u003en\u003c/em\u003e = 41, 31.1%), followed by muscle rupture/strain/tear (\u003cem\u003en\u003c/em\u003e = 30, 22.7%), meniscus/cartilage lesions (\u003cem\u003en\u003c/em\u003e = 19, 14.4%), hematoma/contusion/bruise (\u003cem\u003en\u003c/em\u003e = 11, 8.3%), fracture (\u003cem\u003en\u003c/em\u003e = 10, 7.6%) and tendon injury/bursitis (\u003cem\u003en\u003c/em\u003e = 10, 7.6%).\u003c/p\u003e\n\u003cp\u003eThe most frequent injury mechanism was noncontact (\u003cem\u003en\u003c/em\u003e = 36, 27.3%), followed by contact with another person (\u003cem\u003en\u003c/em\u003e = 35, 26.5%), overuse/chronic (\u003cem\u003en\u003c/em\u003e = 27, 20.5%), contact with the playing surface (\u003cem\u003en\u003c/em\u003e = 17, 12.9%) and contact with the ball (\u003cem\u003en\u003c/em\u003e = 9, 6.8%; Table 2).\u003c/p\u003e\n\u003cp\u003eInjury severity distribution is shown in Figure 1. Among the 132 injuries, 19 involved the head and trunk\u0026mdash;mild and moderate injuries each accounted for 31.6%, minimal injuries for 21.1% and severe injuries for 15.8%. Of the five upper extremity injuries, three were mild and two were severe. Lower extremity injuries accounted for 108 of the total 132 injuries. Among these, severe injuries were most frequent (44.4%), followed by moderate (29.6%), mild (13.0%), minimal (8.3%) and slight (4.6%) injuries.\u003c/p\u003e\n\u003ch2\u003eMost frequent injuries\u003c/h2\u003e\n\u003cp\u003eTable 3 presents a detailed analysis of the five most common injury sites. Ankle sprain/ligamentous injuries were the most frequent, commonly associated with a history of previous ankle injuries (33.3%), severe classification (45.5%) and defender positions (57.6%).\u003c/p\u003e\n\u003cp\u003eKnee injuries ranked second, often related to prior knee injuries (40.0%), meniscus/cartilage lesions (53.3%), noncontact mechanisms (43.3%), severe severity (56.7%) and striker positions (33.3%).\u003c/p\u003e\n\u003cp\u003eThigh injuries ranked third and were primarily muscle ruptures/strains/tears (85.7%), with overuse/chronic (42.9%) and noncontact (38.1%) mechanisms; most were moderate in severity (38.1%).\u003c/p\u003e\n\u003cp\u003eLower leg/Achilles tendon injuries (\u003cem\u003en\u003c/em\u003e = 12) were frequently due to muscle rupture/strain/tear (41.7%) and overuse/chronic mechanisms (58.3%), with most classified as severe (58.3%).\u003c/p\u003e\n\u003cp\u003eFoot/toe injuries (\u003cem\u003en\u003c/em\u003e = 12) comprised various types, were generally severe and involved contact mechanisms more frequently than knee and thigh injuries.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study investigated injury patterns during the 2020 season of the WKFL, which was notably affected by the COVID-19 pandemic. The analysis focused on injury incidence relative to exposure time and examined the distribution of injuries by anatomical location, type, severity, mechanism and player position. Although the primary objective was to describe injury characteristics during this specific season, it is important to acknowledge that pandemic-related disruptions, such as altered training routines, condensed match schedules and limited conditioning, likely influenced the injury landscape. These contextual factors should be considered when comparing our findings with those of prior studies.\u003c/p\u003e\u003cp\u003eThe overall injury incidence was 5.86 per 1,000 h of exposure (95% CI, 4.86\u0026ndash;6.86), with match injuries occurring at a rate 11.50 times higher than those during training (95% CI, 8.15\u0026ndash;16.23). While baseline data from pre-pandemic WKFL seasons are unavailable, similar studies conducted during the pandemic have reported varying trends. For instance, research in UEFA men\u0026rsquo;s professional football reported no significant change in match injury incidence following the lockdown,\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e whereas studies of elite UEFA women\u0026rsquo;s clubs found lower match injury rates during the pandemic-affected season than previous years.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e These discrepancies suggest that injury patterns may differ based on sex, league structure and competitive context.\u003c/p\u003e\u003cp\u003eLower extremity injuries were the most prevalent, aligning with findings from European women\u0026rsquo;s leagues.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Notably, knee injuries were more frequently observed during training, while thigh and foot/toe injuries predominated in matches. These differences likely reflect the divergent physical demands of training and competition. Match play is characterised by high-intensity and aggressive physical engagement, which may lead to more acute injuries. In contrast, training sessions often involve repetitive movements, contributing to the development of overuse injuries.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e This pattern suggests that WKFL players may be particularly susceptible to knee overuse injuries during training, possibly due to repetitive loading and insufficient recovery.\u003c/p\u003e\u003cp\u003eAlthough muscle injuries are generally more common during matches due to higher physical demands,\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e our findings revealed a higher incidence of muscle injuries during training. This observation is consistent with a 5-yr study on the Korean women\u0026rsquo;s national team\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e and may be attributed to the disproportionate exposure time\u0026mdash;20,618 h in training versus only 1,905 h in matches. This training-to-match exposure ratio was substantially higher than those reported in elite leagues in Kosovo (training: 22,375 h; match: 3,748 h)\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e and Spain (training: 21,850 h; match: 3,544 h).\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e The elevated training volume, combined with insufficient physical conditioning and cumulative fatigue, may have contributed to the observed injury trends.\u003csup\u003e\u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Moreover, pandemic-related changes likely exacerbated these issues. Supporting evidence from the German Bundesliga indicated an increase in muscle injuries post-lockdown, attributed to deconditioning and congested match schedules.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Disruptions to regular training programmes may have further compromised players\u0026rsquo; physical readiness.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e These findings underscore the necessity of structured training regimens and appropriate load management to reduce the risk of both muscle and noncontact injuries.\u003c/p\u003e\u003cp\u003eIn contrast, fracture and contusion injuries (hematoma/contusion/bruise) were more common during matches. These injury types typically result from direct impact and high-intensity collisions that are characteristic of competitive match play.\u003csup\u003e\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e Given these environmental demands, implementing injury surveillance systems and optimising training loads are critical steps towards injury prevention. Future research should investigate athletes\u0026rsquo; perceptions of fatigue and workload and assess specific training environments that may predispose players to injury.\u003c/p\u003e\u003cp\u003eRegarding injury mechanisms, contact-related injuries were more frequently reported in matches, with contact with another player occurring 3.76 times more often than in training. This is consistent with the higher physical intensity of match play, especially during tournaments with condensed schedules.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e Conversely, noncontact and overuse injuries predominated in training sessions. A similar trend was reported in Saudi Arabian football post-lockdown, with an increase in noncontact injuries likely resulting from deconditioning.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e As noncontact injuries are more common among female athletes, preventative strategies such as neuromuscular training programmes are crucial.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eHead and facial injuries during matches occurred at a rate 10.36 times higher than during training. Although only one concussion was recorded in this study, head injuries remain a significant concern due to their potential severity. Bundesliga data during the COVID-19 period reported a reduction in head injuries, possibly due to fewer contact duels under modified competition protocols.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e These findings suggest that policy changes may influence injury profiles, although causality has yet to be established. Notably, female athletes have been reported to experience higher concussion rates than their male counterparts.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e This disparity may be due to increased symptom reporting\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e or physiological factors such as reduced neck strength.\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e Given the possibility of underreporting or underrecognition of concussions among female footballers, it is essential to provide education on concussion symptoms and management to both players and coaching staff.\u003c/p\u003e\u003cp\u003eOur findings also revealed position-specific injury patterns. Defenders experienced the highest number of thigh muscle injuries, most of which were noncontact or overuse-related. These injuries often occur during high-intensity actions such as sprinting, sudden directional changes and kicking.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Interestingly, while these movements are typically associated with forwards,\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e defenders in our study were most affected. Similarly, a COVID-19 study in the Bundesliga found that muscle injuries were most prevalent among defenders, especially fullbacks.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Additionally, ankle and foot/toe injuries\u0026mdash;typically caused by contact\u0026mdash;were also common among defenders, likely due to their involvement in tackling, blocking and intercepting.\u003csup\u003e\u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eMidfielders, whose role demands continuous running and endurance,\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e were most frequently affected by lower leg and Achilles tendon injuries, which were predominantly noncontact or overuse in nature. The high physical load associated with the midfielder role likely contributes to the development of these injuries. In contrast, knee injuries\u0026mdash;known for their high severity and recurrence\u0026mdash;were observed across all outfield positions except goalkeepers. Most knee injuries were attributed to noncontact mechanisms, such as pivoting, jumping and landing, which are inherent to football. Anterior cruciate ligament ruptures remain a significant concern in female athletes, given their higher prevalence in this population.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThese position-specific injury trends emphasize the need for tailored prevention strategies in the WKFL. Training and conditioning programmes should be designed to address the biomechanical and workload demands of each playing position, particularly with a focus on reducing noncontact injury risk. Further studies should aim to develop and evaluate targeted interventions that are aligned with the injury profiles of specific field positions.\u003c/p\u003e\u003cp\u003eLimitations\u003c/p\u003e\u003cp\u003eThis study is the first to investigate injury patterns in the WKFL during the COVID-19-impacted 2020 season; however, several limitations should be acknowledged. First, the analysis was limited to a single season, which restricts the ability to assess injury trends across pre-pandemic and post-pandemic periods and limits causal inferences. Second, the study did not include data on players\u0026rsquo; COVID-19 infection status or their physiological responses to exercise during lockdown, which may have influenced injury susceptibility. Lastly, although the study included 138 athletes from six of the eight league teams, the relatively small sample size and partial team participation may affect the generalizability of the findings.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eInjuries during the 2020 pandemic season in women\u0026rsquo;s football occurred more frequently during matches and primarily affected the lower extremities. Injury patterns varied depending on activity type (match vs. training) and player position. Notably, muscle injuries, which are typically more prevalent during competition, were more frequently observed during training. This trend is likely attributable to increased training exposure and inadequate conditioning, exacerbated by the disruptions caused by the pandemic. The COVID-19 crisis introduced significant challenges, including prolonged periods of deconditioning and altered training regimens, both of which may have heightened the risk of injury. To gain a more comprehensive understanding of injury trends, future studies should incorporate extended surveillance across multiple seasons. Additionally, in-depth analyses of training environments and workloads will be essential to inform injury prevention strategies and safeguard athlete health and performance.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e95% CI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;95% confidence interval\u003c/p\u003e\n\u003cp\u003eCOVID-19\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;coronavirus disease 2019\u003c/p\u003e\n\u003cp\u003eFIFA\u0026nbsp; \u0026nbsp;\u0026nbsp;F\u0026eacute;d\u0026eacute;ration Internationale de Football Association\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRR\u003c/em\u003e rate ratio\u003c/p\u003e\n\u003cp\u003eWKFL Korean Women\u0026rsquo;s Professional Football League\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthical approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Yonsei University.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot required.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe data from this study are available from the corresponding author upon request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThis research did not receive any funding from external sources.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003eJae Min Lee\u003c/strong\u003e: Conceptualisation, Data Curation, Formal Analysis, Investigation, Writing\u0026mdash;Original Draft. \u003cstrong\u003eSuji Yoon\u003c/strong\u003e: Conceptualisation, Data Curation, Formal Analysis, Writing\u0026mdash;Original Draft. \u003cstrong\u003eHyung Gyu Jeon\u003c/strong\u003e: Conceptualisation, Data Curation, Formal Analysis, Writing\u0026mdash;Review and Editing. \u003cstrong\u003eSeon Hee Im\u003c/strong\u003e: Project Administration, Conceptualisation, Data Curation, Formal Analysis, Investigation, Writing\u0026mdash;Review and Editing. \u003cstrong\u003eSae Yong Lee\u003c/strong\u003e: Project Administration, Conceptualisation, Data Curation, Formal Analysis, Writing\u0026mdash;Review and Editing.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThis study was conducted in collaboration with the Korean Women\u0026rsquo;s Professional Soccer League. The authors sincerely thank all participating players and team physicians for their invaluable support. Appreciation is also extended to the Institute of Convergence Science at Yonsei University and the International Olympic Committee Research Centre Korea for the Prevention of Injury and Protection of Athlete Health for their institutional support.\u003c/p\u003e\n\u003ch2\u003eClinical trial number\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFIFA. Women's football: member associations survey report. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://inside.fifa.com/womens-football/member-associations-survey-report-2023\u003c/span\u003e\u003cspan address=\"https://inside.fifa.com/womens-football/member-associations-survey-report-2023\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 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Am J Sports Med. 2006;34:299\u0026ndash;311.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 to 3 available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"ankle injury, COVID-19, injury prevention, muscle injury, sports injury, women’s football","lastPublishedDoi":"10.21203/rs.3.rs-7120154/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7120154/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eWomen\u0026rsquo;s football has experienced rapid global expansion in recent years, accompanied by high injury rates. However, prospective epidemiological data on East Asian female players remain scarce, especially during atypical seasons such as the COVID-19 pandemic. This study aimed to characterise the injury patterns in the Korean Women\u0026rsquo;s Professional Football League (WKFL) during the 2020 pandemic season, with a focus on injury location, type, mechanism, severity and positional distribution.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA prospective cohort study was conducted involving 138 elite female athletes from six WKFL teams during the 2020 season. Injury and exposure data were systematically collected after each training session and match using standardised injury surveillance forms. The team coaching staff submitted weekly reports. Injury incidence rates were calculated per 1,000 h of exposure and categorised by injury location, type, mechanism, context (training vs. match) and player position.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eDuring a total exposure time of 22,523 h, 132 injuries were reported. The overall injury incidence rate was 5.86 per 1,000 h (95% confidence interval, 4.86\u0026ndash;6.86). The match injury rate was 11.5 times higher than the training injury rate. The majority of injuries affected the lower extremities (81.8%), with the ankle (25.0%), knee (22.7%) and thigh (15.9%) being the most commonly injured sites. Muscle injuries were more prevalent during training sessions, likely due to extended exposure time and insufficient conditioning. Knee injuries were primarily noncontact and recurrent, observed across all field positions. Defenders exhibited the highest rates of thigh, ankle and foot/toe injuries, whereas midfielders were more susceptible to lower leg and Achilles tendon injuries, predominantly caused by overuse mechanisms.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThis first prospective analysis of injury patterns in the WKFL reveals a predominance of lower extremity injuries and distinct differences in injury profiles between training and match contexts. The COVID-19 pandemic may have exacerbated training-related muscle injuries due to schedule disruptions and inadequate conditioning. The observed position-specific injury trends underscore the importance of tailored injury prevention strategies aligned with the physical demands of each playing role. Longitudinal studies are warranted to guide effective injury mitigation in elite women\u0026rsquo;s football.\u003c/p\u003e","manuscriptTitle":"Injury patterns in the Korean Women’s Professional Football League during the COVID- 19 season: A prospective epidemiological study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-14 11:57:18","doi":"10.21203/rs.3.rs-7120154/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"567fe8f9-6e9c-403f-a899-651630b09ea8","owner":[],"postedDate":"August 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-19T10:09:17+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-14 11:57:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7120154","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7120154","identity":"rs-7120154","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}