Abstract
Background:
Anterior shoulder dislocation is an injury that can impair a professional goalkeeper's career. However, few studies have examined return to play (RTP) after surgery in professional goalkeepers.
Purpose:
To assess the RTP, pre- and postinjury performances, and market value of professional goalkeepers who suffered a shoulder dislocation.
Study Design:
Descriptive epidemiology study.
Methods:
Professional goalkeepers with a shoulder dislocation between 2011 and 2021 were included. Top European leagues were considered: Serie A (Italy), Premier League (England), Ligue 1 (France), LaLiga (Spain), and Bundesliga (Germany). Player age, height, position, injury history, RTP, and market value were retrieved from a publicly available website. The preinjury season (season −1), the injury season (season 0), and the 2 postinjury seasons (season +1 and season +2) were compared.
Results:
A total of 19 goalkeepers were included in the study with a mean age of 27.2 ± 5.22 years at the time of injury. All players underwent surgery. The mean RTP was 147.53 ± 64.23 days. The mean percentage minutes per season (MPS) in season −1 was 86.57% ± 13.89%, with a decrease to 37.34% ± 24.66% in the injury season and an increase to 72.72% ± 25.79% in season +1 and 62.69% ± 33.23% in season +2. Significant changes were found in MPS across the 4 analyzed seasons (P < .001). Post hoc comparisons revealed statistically significant differences between season −1 and season 0 (P < .001), season −1 and season +1 (P = .019), and season −1 and season +2 (P = .005). The difference between season +1 and season +2 was not statistically significant (P = .284). The mean market values were €7.13M ±€8.33M (season −1), €8.05M ±€8.25M (season 0), €8.71M ±€11.45M (season +1), and €11.47M ±€22.89M (season +2). Regarding market value, no significant differences were detected among the seasons (P = .285). All goalkeepers returned to play after the surgery, with 1 case (5.3%) at a lower level.
Conclusion:
All professional goalkeepers returned to play at a competitive level with a significant reduction in the percentage of available minutes played in the 2 seasons after surgery. However, this injury does not seem to influence the market value of these players.
Keywords: shoulder dislocation, professional goalkeepers, return to play
Soccer has the most significant number of players injured yearly. 14 Historically, shoulder injuries are less frequent than lower limb injuries. 13 An elite soccer player experiences from 1.5 to 7.6 injuries per 1000 training hours and from 12 to 35 injuries per 1000 match hours.7,12
A prospective cohort study of European professional male teams found that shoulder injuries represented 2% of all injuries during the years 2001 to 2008, 8 while they represented 3.3% according to another retrospective analysis of shoulder injuries in Premier League professional soccer players between 2006 and 2010. 15 The high-speed game, dangerous tactical situations, and direct effects during the game lead the player to fall frequently, with different types of injuries, including fractures and dislocations. 13
Goalkeepers (GKs) should be studied separately from field players.6,17 The actions of GKs include different dynamic movements of the shoulders, which can lead to muscle and tendon injuries. 14 Upper extremity injuries are reported to be up to 5 times more common in GKs than in field players.7,8 In an analysis of shoulder and elbow injuries in GKs versus field players, GKs had more elbow and shoulder injuries than field players (8.3 vs 1.8 incidents) per 10,000 athletic exposures. 9 Among the upper body injuries, the most common were acromioclavicular joint injuries, rotator cuff tears/sprains, and elbow/shoulder instability. 9
Anterior shoulder dislocations are common during the season in young athletes. 1 Usually, critical shoulder injuries in sports happen during a position of combined humeral abduction and external rotation against a force of internal rotation and horizontal extension, resulting in anterior dislocation. 11 In >93% of cases, including American football, basketball, baseball, wrestling, volleyball, basketball, and softball, shoulder dislocation is the consequence of player-to-player contact or player-to-ground contact. 2 The severity of shoulder injuries experienced in professional soccer is of great concern. Nearly one-third of shoulder injuries (28%) sustained by professional soccer players are severe (causing an absence >28 days in training and games), 8 with negative economic impact. 5
Data involving the results of the management of shoulder instability in professional GKs are limited. The purpose of the study was to clarify some points about shoulder dislocation in elite soccer GKs and evaluate the primary therapeutic choice, the return to play (RTP), the part of the game when the trauma occurs, the percentage of minutes played, and the economic value of the player in the season before and the 2 seasons after the injury.
Methods
In this retrospective study, the authors identified male professional soccer GKs who sustained an anterior glenohumeral dislocation (aGHD) between 2011 and 2021 and belonged to the first-team rosters. Leagues that were included were Serie A (Italy), Premier League (England), Ligue 1 (France), La Liga (Spain), and Bundesliga (Germany).
Information about age at the injury, height, weight, body mass index (BMI), affected side, year, team, medical treatment, injury history, injury match time, RTP time, number of matches missed, percentage of played minutes per season (MPS), and economic value the season before and the 2 seasons after shoulder dislocation was retrieved from the publicly available media-based platform Transfermarkt (https://www.transfermarkt.com/). Transfermarkt is an accurate German website containing detailed soccer information, such as league tables, results, transfers, player careers, demographic data, precise injury data (season, type, date, missed matches), and club data. Additional data were retrieved through other publicly available online sources, such as national sport newspapers.
RTP time was assessed as the number of days from a shoulder dislocation injury to the first match appearance. MPS was defined as the percentage of minutes played divided by the total playable minutes during each season. The mean percentage MPS was calculated for the injury season (season 0), the preinjury season (MPS −1), and the 2 postinjury seasons (season +1 and season +2). The percentage MPS during the first postoperative season was measured by the total playable minutes since the RTP date (Table 1).
Table 1.
Operational Definitions Used in the Study
| Term | Definition |
|---|---|
| Injury | Injury resulting from playing soccer and leading to a player being unable to participate fully in future match play |
| Severe injury | Injury causing >28 days’ absence from training and match play |
| Training injury | Injury during a training session |
| Match injury | Injury during a match |
| Match day | Day on which a soccer match takes place |
| Return to play | No. of days from injury to the first match appearance with the first team, reserve team, youth team, or national team |
| Return-to-play rate | Percentage of players who came back from injury to the first match appearance with the first team, reserve team, youth team, or national team |
| Minute per season | Minutes played divided by total playable minutes in a season |
| Market value | Economic value of the player at the end of the season (June) |
| season −1 | Season before the injury |
| Season 0 | Season of the injury |
| Season +1 | Season after the injury |
| Season +2 | Second season after the injury |
Players who were transferred to other clubs, changed to a lower league, or had other injuries after the index injury of the analysis but did not stop their career before the end of the second season after injuries were recorded. According to the United European Football Association (UEFA) country ranking, the downgraded leagues were defined as being transferred to an inferior competitive level according to the UEFA country ranking. UEFA calculates the coefficient of each club each season based on the clubs’ results in the UEFA Champions League, UEFA Europa League, and UEFA Conference League.
Players were excluded from the MPS evaluation if they did not play >50% of MPS in season −1, if they were injured during the summer season, if they experienced other severe injuries in the same season, if they retired, or if data were not available. Age at injury, height, weight, BMI, affected side, year, team, treatment choice, injury history, RTP time, number of matches missed, MPS, and economic value were considered for the entire patient cohort.
Statistical analysis was performed using SPSS Statistics software (Version 28.0.1.1; IBM Corp). Continuous variables are presented as mean ± standard deviation, or percentages where appropriate.
The normality of the data and the distribution of MPS and market value variables across the 4 seasons were assessed using the Kolmogorov-Smirnov and Shapiro-Wilk tests. Both MPS and market value variables violated the assumption of normal distribution (Kolmogorov-Smirnov test, all P < .05). Therefore, the Friedman test was used to compare repeated measures across the 4 seasons (season −1, season 0, season +1, and season +2). Post hoc pairwise comparisons between seasons were performed using Wilcoxon signed-rank tests with Bonferroni correction for multiple comparisons. Statistical significance was set at a P value <.05.
Results
The initial population included 34 GKs, all undergoing shoulder instability surgery with a minimum 2-year follow-up. We excluded 5 GKs with missing study data, 7 GKs who played <50% of MPS in season −1, another 2 who were injured in the summer season, and 1 GK who had another severe injury in the same season as the glenohumeral dislocation (GHD) injury, resulting in a final sample of 19 patients (mean age, 27.2 ± 5.22 years). Participant data were recorded (Table 2).
Table 2.
Participant Data (N = 19) a
| Value | |
|---|---|
| Age, y | 27.15 ± 5.22 |
| Height, m | 1.89 ± 0.04 |
| Weight, kg | 82.89 ± 6.42 |
| BMI, kg/m2 | 23.18 ± 1.77 |
| Injured side: right | 52.6% |
| Injured side: left | 47.4% |
| Match injury | 68.42% |
| Training injury | 31.58% |
| Injury match time: 0-45 min | 61.54% |
| Injury match time: 46-90 min | 38.46% |
| Matches missed | 19.95 ± 0.48 |
| Return to play, days | 147.53 ± 64.23 |
| Return-to-play rate | 100% |
| League downgrade | 5.3% |
| Ended career | 0% |
| Treatment: surgery | 100% |
| Treatment: medical | 0% |
Data are presented as mean ± SD or percentage. BMI, body mass index.
Most of the aGHDs occurred in the later minutes of a given half, and the less common injury intervals were 0 to 15 minutes (6.25%) and 45 to 60 minutes (6.25%). Overall, 68.42% of the cases occurred during match play as opposed to training. All players had surgery within 35 days of the injury, and 90.5% within 21 days. The mean RTP was 147.53 ± 64.23 days, with a mean of 19.95 ± 0.48 missed games.
The mean percentage MPS before the injury was 86.57% ± 13.89%, decreasing to 37.34% ± 24.66% in the season of the injury, going back up to 72.72% ± 25.79% in season +1, and descending to 62.69% ± 33.23% in season +2. Significant changes were found in MPS across the 4 analyzed seasons (χ2 = 26.28; df = 3; P < .001). Post hoc comparisons revealed statistically significant differences between season −1 and season 0 (Z = −3.823; P < .001), season −1 and season +1 (Z = −2.345; P = .019), and season −1 and season +2 (Z = −2.817; P = .005). The difference between season +1 and season +2 was not statistically significant (Z = −1.071; P = .284). The mean market value in season −1 was €7.13M ±€8.33M. At the season of the injury, it was €8.05M ±€8.25M. At season +1, it was €8.71M ±€11.45M, while in season +2, it was €11.47M ±€22.89M. Regarding market value, no significant differences were detected across the seasons (χ2 = 3.792; P = .285). Player performance metrics exhibited variations but lacked statistical significance. All GKs (100%) returned to play after the surgery, and 1 (5.3%) was transferred to a lower competitive level in the second season after injury.
Discussion
The main findings of the current study were that all the GKs who dislocated their shoulders underwent surgery. All the players returned to the sport, and all but one (18/19) returned to the same level in the season after surgery.
To the best of our knowledge, the present study reports the most extensive series of elite soccer GKs experiencing an aGHD. Only some studies of elite soccer GKs are available in the literature.3,4,10,16 The present study underlines the efficacy of surgical treatment for GKs with a complete return to sports, resulting in a high RTP rate in a reasonable time (mean RTP, 147.53 ± 64.23 days). These findings agree with recent literature. Castagna et al 3 evaluated the return to sport after surgical treatment of shoulder injuries in 19 professional GKs in relation to the mechanism of injury and the pattern of related shoulder lesions. Of these injuries, 6 were acute aGHD and 3 were recurrent GHD. The authors found that elite professional GKs who underwent shoulder surgery experienced a high rate of return to sport, considering that 95.8% of players reported a subjective level of return to sport of at least 80% and 79.2% reported a level of at least 90%, with a mean RTP time of 142.8 ± 32.2 days. Hart and Funk 10 reported good results at a short-term follow-up for 5 professional GKs who sustained severe shoulder injuries, with a mean RTP time of 77.7 days without recurrences. Cerciello et al 4 reported the long-term results of the Latarjet procedure for 8 professional GKs, with a 100% return-to-sport rate after 140 days, with 12.5% experiencing a redislocation and 14.43% reporting discomfort. Terra et al, 16 in a series of 12 GKs, reported the results of arthroscopy for GHDs at a mean of 3.8 years, with excellent or good results observed in 80% of cases of acute instability and 57.2% of cases of recurrent instability, with no limitation of sports activities and a return to 90% to 100% of the preinjury level.
The RTP rate alone does not provide a clear insight into how players perform once they return to competition. For that reason, we use the concept of percentage MPS to have a more complete picture of how aGHD influences playing time. The present study revealed how the aGHD could negatively influence the performance and career of the GKs. In fact, we found a statistically significant decrease in the percentage MPS between season −1 and season 0, season −1 and season +1, and season −1 and season +2, while a negative trend was observed in the percentage MPS between season +1 and season +2.
From the data presented in the study, in 68.42% of cases, the injury happened during the match. These data are consistent with the study by Hart and Funk, 10 who found that 64% of participants sustained an injury during match play and 16% during training. In comparison, injuries that presented as ongoing symptoms in both training and matches were described in 20% of players. 10
We focused on the minutes in which injuries occurred. The injury intervals less common were 0 to 15 minutes (6.25%) and 45 to 60 minutes (6.25%), with a significantly higher risk in the second part of each halftime, probably due to the increased number of actions played by GKs during that part of the match. Furthermore, this study investigated the economic value variations of the players after aGHDs and found no significant increase or decrease in the mean economic value of the players over the seasons.
One of the strengths of this study is the type of athlete involved, considering the difficulties in admitting athletes with this type of shoulder injury for inclusion in such analyses. The current study investigated the effect of aGHD, in terms of RTP rate/time and player performance.
Limitations
The present study presents some limitations because data were retrieved from public online sources. As we used only online information, the number of participants was limited, and no medical records, imaging, information about associated lesions, surgical techniques, or rehabilitation programs were available. Such factors may play a role in players’ recovery and performance after an aGHD, and the analysis of data categorizing those variables could be valuable. However, because an injury database like those used in the National Football League or the National Basketball Association does not exist for soccer, such sources represent the best available and independent option and have been previously used successfully in other similar studies. Moreover, the lack of a control group does not allow for a comparison of players who underwent surgery after GHD and healthy players regarding performance and career outcomes.
Conclusion
All elite soccer GKs analyzed in the present study underwent surgery after an aGHD and fully recovered and returned to play. However, a significant decline in the percentage of minutes played was observed during the 2 seasons after the surgery. Furthermore, this injury does not appear to affect the players’ market value.
Footnotes
Final revision submitted March 22, 2025; accepted April 17, 2025.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
Ethical approval was not sought for the present study.
References
- 1. Alentorn-Geli E, Álvarez-Díaz P, Doblas J, et al. Return to sports after arthroscopic capsulolabral repair using knotless suture anchors for anterior shoulder instability in soccer players: minimum 5-year follow-up study. Knee Surg Sports Traumatol Arthrosc. 2015;24(2):440-446. [DOI] [PubMed] [Google Scholar]
- 2. Bonza JE, Fields SK, Yard EE, Comstock RD. Shoulder injuries among United States high school athletes during the 2005–2006 and 2006–2007 school years. J Athl Train. 2009;44(1):76-83. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Castagna A, Ranieri R, Volpi P, Ceccarelli E, Garofalo R, Conti M. Elite professional goalkeepers report high rate of sport resumption after shoulder surgery. Knee Surg Sports Traumatol Arthrosc. 2021;29(12):3943-3950. [DOI] [PubMed] [Google Scholar]
- 4. Cerciello S, Edwards TB, Walch G. Chronic anterior glenohumeral instability in soccer players: results for a series of 28 shoulders treated with the Latarjet procedure. J Orthop Traumatol. 2012;13(4):197-202. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Comin J, Malliaras P, Baquie P, Barbour T, Connell D. Return to competitive play after hamstring injuries involving disruption of the central tendon. Am J Sports Med. 2012;41(1):111-115. [DOI] [PubMed] [Google Scholar]
- 6. Della Villa F, Mandelbaum BR, Lemak LJ. The effect of playing position on injury risk in male soccer players: systematic review of the literature and risk considerations for each playing position. Am J Orthop (Belle Mead NJ). 2018;47(10). [DOI] [PubMed] [Google Scholar]
- 7. Ejnisman B, Andreoli CV, de Castro Pochini A, et al. Shoulder injuries in soccer goalkeepers: review and development of a FIFA 11+ shoulder injury prevention program. Open Access J Sports Med. 2016;8(7):75-80. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Ekstrand J, Hagglund M, Walden M. Injury incidence and injury patterns in professional football: the UEFA injury study. Br J Sports Med. 2009;45(7):553-558. [DOI] [PubMed] [Google Scholar]
- 9. Goodman AD, Etzel C, Raducha JE, Owens BD. Shoulder and elbow injuries in soccer goalkeepers versus field players in the National Collegiate Athletic Association, 2009–2010 through 2013–2014. Phys Sportsmed. 2018;46(3):304-311. [DOI] [PubMed] [Google Scholar]
- 10. Hart D, Funk L. Serious shoulder injuries in professional soccer: return to participation after surgery. Knee Surg Sports Traumatol Arthrosc. 2013;23(7):2123-2129. [DOI] [PubMed] [Google Scholar]
- 11. Hudson VJ. Evaluation, diagnosis, and treatment of shoulder injuries in athletes. Clin Sports Med. 2010;29(1):19-32. [DOI] [PubMed] [Google Scholar]
- 12. Kirkendall DT, Dvorak J. Effective injury prevention in soccer. Phys Sportsmed. 2010;38(1):147-157. [DOI] [PubMed] [Google Scholar]
- 13. Longo UG, Loppini M, Berton A, Martinelli N, Maffulli N, Denaro V. Shoulder injuries in soccer players. Clin Cases Miner Bone Metab. 2012;9(3):138-141. [PMC free article] [PubMed] [Google Scholar]
- 14. Muracki J, Klich S, Kawczyński A, Boudreau SA. Injuries and pain associated with goalkeeping in football—review of the literature. Appl Sci. 2021;11(10):46-69. [Google Scholar]
- 15. Pritchard C, Mills S, Funk L, Batty P. Incidence and management of shoulder injuries in Premier League professional football players. Br J Sports Med. 2011;45(15):A15. [Google Scholar]
- 16. Terra B, Ejnisman B, Figueiredo E, et al. Arthroscopic treatment of glenohumeral instability in soccer goalkeepers. Int J Sports Med. 2012;34(06):473-476. [DOI] [PubMed] [Google Scholar]
- 17. White A, Hills SP, Cooke CB, et al. Match-play and performance test responses of soccer goalkeepers: a review of current literature. Sports Med. 2018;48(11):2497-2516. [DOI] [PubMed] [Google Scholar]