Abstract
Background:
Despite soccer's popularity in Egypt, no comprehensive epidemiological studies have examined injury distribution by playing position.
Purpose:
To characterize the injury profile of Egyptian professional soccer players and assess differences by playing position.
Study Design:
Cohort study; Level of evidence, 2.
Methods:
A prospective cohort study was conducted across 12 soccer clubs in the Egyptian professional league during the 2022 to 2023 season. Player exposure was recorded using a standardized form. Injuries were documented by medical staff. Data were collected on player demographics, injury profile, and diagnostic modalities. Associations between categorical injury variables and position were assessed using chi-square tests with Cramér V, followed by post hoc analysis using adjusted residuals.
Results:
Among 384 male players, midfielders were the largest group (38.5%), followed by forwards (27.9%), defenders (22.1%), and goalkeepers (11.5%). There were 422 time-loss injuries (incidence: 2.36/1000 player-hours). Goalkeepers were taller (182 ± 5 cm) and heavier (74.5 ± 3.9 kg) than defenders (178 ± 4 cm; 70.2 ± 5.1 kg), midfielders (175 ± 3 cm; 67.2 ± 4.8 kg), and forwards (175 ± 4 cm; 67.1 ± 5.5 kg); all P < .001. Exposure hours differed by position (P = .007): goalkeepers, 403.7 ± 112.9 h; defenders, 405.1 ± 108.5 h; midfielders, 447.3 ± 106.7 h; and forwards, 411.8 ± 108.9 h. Injury incidence showed no positional variation (P = .07): goalkeepers, 2.54 (IQR, 2.1-3.2); defenders, 2.38 (IQR, 2.2-3.2); midfielders, 2.19 (IQR, 1.9-3.1); and forwards, 2.38 (IQR, 2.1-3.2) per 1000 h. Goalkeepers sustained more nervous system/soft tissue injuries, upper limb/head injuries, contact injuries, first-time training injuries, and minimal degree injuries, and were more often diagnosed by imaging. Among outfield players, defenders were taller and heavier, midfielders had more overstretch injuries with shorter layoffs, and forwards had more severe injuries. Outfield injuries relied more on clinical assessment (36.1%).
Conclusion:
Our study showed that injury patterns among Egyptian professional soccer players vary significantly by playing position. While muscle/tendon and lower limb injuries are common overall, the 4 positions exhibit distinct anthropometric, injury mechanism, site, severity, and diagnostic profiles. These findings recommend position-specific injury prevention and rehabilitation in Egyptian professional soccer.
Keywords: sports injuries, playing position, soccer, epidemiology, Egyptian Professional League, prospective studies
Soccer (football) is one of the most popular sports worldwide and is played by as many as 200 million athletes at different competitive levels. 5 The Egyptian Football Association (EFA) was established in 1921 and became a member of the International Federation of Association Football (FIFA) in 1923. Registered soccer players in Egypt constitute around 750,320 players of both sexes and all ages and competitive levels across the country. Soccer has a high injury rate among team sports; this may be due to the demanding combination of high-intensity action and frequent physical contact. 13 This incidence is further elevated in professional players because of the increased speed and intensity compared with amateur players. 5
Soccer injuries have adverse effects on team performance and significant economic implications. Research from Europe shows that if a player is injured and cannot play for 1 month, it can cost a club about €500,000 (approximately USD$545,000). Over an entire season, these financial losses for a club can be >€ 53 million (roughly USD$58 million). 13 So, every effort should be made to prevent these injuries. The first step in any prevention strategy is to study the epidemiology of these injuries and demonstrate their profile. 13 Such prospective epidemiological studies are expected to use consistent, measurable metrics to track injuries, recovery progress, and program effectiveness. 3
Development of injuries in soccer is influenced by several factors, including the physical and tactical demands of the sport, external environmental conditions, and intrinsic player characteristics. 17 Among these, playing position determines the type and frequency of physical activities performed during matches. Each playing position on a team has specific physical, physiological, and technical demands. These distinct demands contribute to position-specific patterns of injury. 17 These demonstrated playing position effects underscore the importance of position-specific training practice for injury prevention.
Despite soccer's popularity in Egypt and the Middle East, there are no comprehensive epidemiological studies examining injury distribution particularly in relation to tactical position across the country. Most existing literature originates from European or South American leagues and thus may not fully reflect the contextual and training differences in the Egyptian setting. 19 The purpose of this study is to characterize the injury profile of Egyptian professional soccer players by evaluating the variations in injury type, mechanism, severity, recurrence, and diagnostic methods used in different tactical positions. The hypothesis was that playing position would be significantly associated with specific injury characteristics.
Methods
Study Design and Ethical Considerations
This is a prospective cohort study conducted throughout the 2022 to 2023 season (October 2022–June 2023). The cohort comprised players from 12 professional clubs in the Egyptian first and second divisions. The clubs included are Ettihad, Sporting, Olympic, Somouha, Pharco, Al-nasr, Mokawloon, Ismaily, Al-masry, Aswan, Al-mahalla, and Petrojet.
Ethical approval was obtained from Ain Shams University. Written consent was obtained from clubs and players. Each participant was assigned a unique study identification code, and all personal identifiers were removed prior to data aggregation and statistical analysis. Identifiable medical information remained accessible only to the respective club medical teams and was not shared with the research analysts.
Participants and Preseason Assessment
Eligible participants were male players aged 18 to 35 years listed on a club's first-team roster. Players with preexisting injuries at the preseason screening were included in the study, but their existing conditions were excluded from the analysis of in-season injuries.
Exclusion criteria included interclub transfer during the season, absence from training or matches for >6 weeks for noninjury reasons, time-loss injuries lasting >6 months, injuries sustained during the season without a return to play before the season concluded, and injuries incurred outside of official soccer activities.
Preseason screening involved the FIFA Pre-Competition Medical Assessment forms 4 and the Oslo Sports Trauma Research Center overuse injury questionnaire. 2 Of 525 initially assessed players, 8 were excluded for preexisting injuries lasting >6 months, 23 for incomplete preseason screening, 7 for non–soccer related injuries, 15 because of transfers, and 88 players from 2 clubs where managerial changes compromised data consistency. The final analyzed cohort consisted of 384 players.
Exposure and Injury Definition
Player exposure was recorded in hours for all training sessions and matches (both club and national team) using a standardized form. A member of the medical staff attended sessions to record injuries. An injury was defined as any condition resulting in ≥1 day of absence from training or matches (time-loss injury). 6
Data Collection
Data were categorized into 3 domains:
Player characteristics: age, anthropometrics (height, weight, body mass index [BMI]), total weekly and seasonal exposure hours, and injury incidence (per 1000 player-hours). Playing positions were classified as goalkeeper, defender, midfielder (including defensive and advanced), or forwards (including wingers and strikers)
Injury profile: type (joint/ligament, muscle/tendon, bone, nervous system, soft tissue (ie, skin and subcutaneous tissue), anatomical site (upper limb, lower limb, trunk, head), mechanism (contact: direct blow, fall; noncontact: overstretching, twisting; overuse), context (match vs training), classification (first-time vs reinjury), and severity. Severity was graded by layoff time: minimal (1-3 days), mild (4-7 days), moderate (8-28 days), severe (>28 days) 6
Diagnostic modality: clinical assessment, plain radiography (PXR), magnetic resonance imaging (MRI), computed tomography (CT), or ultrasonography (US).
Statistical Analysis
The sample size was calculated using the formula for prevalence studies. 1 Assuming a 75% prevalence of lower limb injuries with a 95% CI and 5% margin of error, 12 a minimum of 289 players was required. This was adjusted to 321 to account for a 10% attrition rate.
Data were analyzed using IBM SPSS Statistics for Windows (Version 27.0; IBM Corp). Continuous variables are presented as mean ± SD for parametric data or as median and interquartile range for nonparametric data. Categorical variables are expressed as frequencies and percentages. Normality was assessed using the Kolmogorov-Smirnov test. For comparisons among >2 groups, parametric data were analyzed using 1-way analysis of variance, with post hoc least significant difference testing when significant differences were identified. Nonparametric data were analyzed using the Kruskal-Wallis test, followed by pairwise Mann-Whitney U tests for post hoc comparison.
Associations between categorical variables were assessed using the chi-square test or Fisher exact test (when expected cell counts were <5). The strength of association for significant chi-square tests was measured using Cramér V. Adjusted residuals were examined to identify cells contributing most to a significant chi-square result. A P value <.05 was considered statistically significant for all tests.
Results
Player Characteristics
The study included 384 players registered at the EFA. The mean ± SD age was 25.1 ± 4.5 years. The mean height was 177.0 ± 0.1 cm, mean weight was 68.7 ± 5.5 kg, and mean BMI was 22.0 ± 1.3 kg/m2. The mean player total exposure time was 14.1 ± 2.7 hours per week and 423.0 ± 109.7 hours per season. The overall injury incidence was 2.36 injuries per 1000 player-hours (IQR, 2.0-3.2). Players' positional distribution revealed that midfielders constituted the largest group (38.5%; n = 148), followed by forwards (27.9%; n = 107), defenders (22.1%; n = 85), and goalkeepers (11.5%; n = 44) (Table 1).
Table 1.
Player Characteristics (N = 385) a
| Characteristic | Value |
|---|---|
| Age, y | 25.1 ± 4.5 |
| Height, cm | 177.0 ± 0.1 |
| Weight, kg | 68.7 ± 5.5 |
| BMI, kg/m2 | 22.0 ± 1.3 |
| Playing position | |
| Goalkeeper | 44 (11.5) |
| Defender | 85 (22.1) |
| Midfielder | 148 (38.5) |
| Forward | 107 (27.9) |
| Weekly exposure, h | 14.1 ± 2.7 |
| Seasonal exposure, h | 423.0 ± 109.7 |
| Overall injury incidence per 1000 player-hours, median (IQR) | 2.36 (2.0-3.2) |
Data are presented as mean ± SD or n (%) unless otherwise indicated.
Injury Profile
A total of 422 injuries were recorded. The most frequent injury type was muscle/tendon (43.8%; n = 185), followed by joint/ligament (31.8%; n = 134), bone (14.5%; n = 61), central/peripheral nervous system (7.8%; n = 33), and other soft tissue injuries (2.1%; n = 9). The most frequent injury site was the lower limb (73.7%; n = 311), followed by the upper limb (12.8%; n = 54), head (11.6%; n = 49), and trunk (1.9%; n = 8). The anatomical distribution of lower limb injuries showed that the thigh was the most commonly affected site, accounting for 49.8% of injuries, followed by the ankle (31.8%), knee (14.5%), foot (2.6%), and groin/hip 196 (1.3%).
The leading injury mechanisms were twisting (28.4%; n = 120), overstretching (26.8%; n = 113), and blows (22.3%; n = 94), with overuse (11.8%) and falls (10.7%) being less common. Injuries occurred slightly more often during matches (51.2%; n = 216) than training (48.8%; n = 206), and first-time injuries (51.2%; n = 216) were marginally more frequent than reinjuries (48.8%; n = 206). The median injury layoff was 21 days (IQR, 10-32 days). Moderate injuries were most common (62.6%; n = 264), followed by severe (24.9%) and mild (11.6%) injuries; minimal injuries were rare (0.9%; n = 4) (Table 2).
Table 2.
Injury Profile (n = 422 injuries)
| Injury Characteristic | n | % |
|---|---|---|
| Type | ||
| Muscle/tendon | 185 | 43.8 |
| Joint/ligament | 134 | 31.8 |
| Bone | 61 | 14.5 |
| Central/peripheral nervous system | 33 | 7.8 |
| Other soft tissue | 9 | 2.1 |
| Site | ||
| Lower limb | 311 | 73.7 |
| Upper limb | 54 | 12.8 |
| Head | 49 | 11.6 |
| Trunk | 8 | 1.9 |
| Mechanism | ||
| Twisting | 120 | 28.4 |
| Overstretching | 113 | 26.8 |
| Blow (contact) | 94 | 22.3 |
| Overuse | 50 | 11.8 |
| Fall | 45 | 10.7 |
| Context | ||
| Match | 216 | 51.2 |
| Training | 206 | 48.8 |
| Classification | ||
| First-time | 216 | 51.2 |
| Reinjury | 206 | 48.8 |
| Severity (layoff time) | ||
| Minimal, 1-3 d | 4 | 0.9 |
| Mild, 4-7 d | 49 | 11.6 |
| Moderate, 8-28 d | 264 | 62.6 |
| Severe, >28 d | 105 | 24.9 |
| Layoff time, d, median (IQR) | 21 (10-32) | |
Diagnostic Modalities
A total of 441 diagnostic procedures were utilized. Clinical assessment was the most frequent (36.1%; n = 159), followed by PXR (26.1%; n = 115). Advanced imaging accounted for the remainder: US (17.7%; n = 78), MRI (11.8%; n = 52), and CT (8.4%; n = 37).
Player Characteristic by Position
Player age did not differ significantly across positions. Significant differences were observed for height, weight, and BMI (P < .001, P < .001, and P = .03, respectively). Goalkeepers were significantly taller and heavier than all outfield positions (P < .001) and had a higher BMI than forwards (P = .007). Defenders were also significantly taller and heavier than midfielders and forwards (P < .001) (Table 3).
Table 3.
Comparison of Player Characteristics by Playing Position: Age, Height, Weight, BMI, Weekly Exposure, and Seasonal Exposure a
| Goalkeeper | Defender | Midfielder | Forward | Test Value | P | |
|---|---|---|---|---|---|---|
| n = 44 | n = 85 | n = 148 | n = 107 | |||
| Age, y | 25.98 ± 5.08 | 25.72 ± 4.98 | 25.23 ± 4.06 | 24.21 ± 4.23 | 2.560 b | .06 |
| Height, m | 182 ± 5 | 178 ± 4 | 175 ± 3 | 175 ± 4 | 49.442 b | <.001 |
| Weight, kg | 74.52 ± 3.86 | 70.15 ± 5.06 | 67.16 ± 4.84 | 67.11 ± 5.46 | 30.914 b | <.001 |
| BMI, kg/m2 | 22.39 ± 1.01 | 22.14 ± 1.30 | 21.96 ± 1.34 | 21.77 ± 1.24 | 2.921 b | .03 |
| Weekly exposure, h | 14.05 ± 3.21 | 13.65 ± 2.58 | 14.47 ± 2.59 | 14.06 ± 2.83 | 1.700 b | .17 |
| Seasonal exposure, h | 403.68 ± 112.94 | 405.05 ± 108.52 | 447.26 ± 106.67 | 411.84 ± 108.89 | 4.089 b | .007 |
| Injury incidence, per 1000, h, median (IQR) | 2.54 (2.13-3.20) | 2.38 (2.17-3.21) | 2.19 (1.9-3.07) | 2.38 (2.08-3.21) | 7.064 c | .07 |
| Post hoc analysis d | ||||||
| Parameter | Goalkeepers | Defenders | Midfielders | |||
| vs. Defenders | vs. Midfielders | vs. Forwards | vs. Midfielders | vs. Forwards | vs. Forwards | |
| Height | <.001 | <.001 | <.001 | <.001 | <.001 | .19 |
| Weight | <.001 | <.001 | <.001 | <.001 | <.001 | .95 |
| BMI | .29 | .05 | .007 | .30 | .046 | .24 |
| Seasonal exposure | .95 | .02 | .68 | .004 | .67 | .01 |
Data are presented as mean ± SD unless otherwise indicated. BMI, body mass index. Values in bold indicate statistical significance.
One-way analysis of variance test.
Kruskal-Wallis test.
Data presented as P value.
Seasonal exposure hours differed significantly by position (P = .007), with midfielders having greater exposure than other positions. Injury incidence per 1000 player-hours showed no significant positional variation (P = .07) (Table 3).
Injury Profile by Position
Muscle/tendon injuries were the most common injury type across all positions. A significant but weak association was found between playing position and injury type (χ2 = 42.8; P < .001; Cramér V = 0.18) (Table 4). Post hoc analysis of adjusted residuals (Table 5) showed that goalkeepers sustained significantly more nervous system and soft tissue injuries and fewer muscle/tendon injuries than expected. Outfield positions did not deviate significantly from expected injury type frequencies.
Table 4.
Comparison of Injury Profile by Playing Position a
| Goalkeeper | Defender | Midfielder | Forward | Test Value |
P | Cramér V test |
||
|---|---|---|---|---|---|---|---|---|
| n = 49 | n = 93 | n = 166 | n = 114 | |||||
| Injury type | Bone | 8 (16.3) | 14 (15.1) | 24 (14.5) | 15 (13.2) | 42.83 b | <.001 | 0.184 (weak) |
| Joint/ligament | 7 (14.3) | 30 (32.3) | 54 (32.5) | 43 (37.7) | ||||
| Muscle/tendon | 17 (34.7) | 41 (44.1) | 77 (46.4) | 50 (43.9) | ||||
| Soft tissue | 4 (8.2) | 1 (1.1) | 3 (1.8) | 1 (0.9) | ||||
| Central/peripheral nervous system | 13 (26.5) | 7 (7.5) | 8 (4.8) | 5 (4.4) | ||||
| Injury anatomical site | Upper limb | 22 (44.9) | 4 (4.3) | 14 (8.4) | 14 (12.3) | 93.62 b | <.001 | 0.272 (moderate) |
| Lower limb | 10 (20.4) | 77 (82.8) | 135 (81.3) | 89 (78.1) | ||||
| Trunk | 1 (2.0) | 1 (1.1) | 2 (1.2) | 4 (3.5) | ||||
| Head | 16 (32.7) | 11 (11.8) | 15 (9.0) | 7 (6.1) | ||||
| Mechanism of injury | Blow | 18 (36.7) | 23 (24.7) | 32 (19.3) | 21 (18.4) | 48.10 b | <.001 | 0.195 (weak) |
| Overstretch | 4 (8.2) | 22 (23.7) | 55 (33.1) | 32 (28.1) | ||||
| Twisting | 3 (6.1) | 28 (30.1) | 53 (31.9) | 36 (31.6) | ||||
| Fall | 13 (26.5) | 6 (6.5) | 12 (7.2) | 14 (12.3) | ||||
| Overuse | 11 (22.4) | 14 (15.1) | 14 (8.4) | 11 (9.6) | ||||
| Context | Match | 12 (24.5) | 47 (50.5) | 90 (54.2) | 67 (58.8) | 17.23 b | .001 | 0.202 (moderate) |
| Training | 37 (75.5) | 46 (49.5) | 76 (45.8) | 47 (41.2) | ||||
| Classification | First time | 37 (75.5) | 44 (47.3) | 75 (45.2) | 60 (52.6) | 14.65 b | .002 | 0.186 (weak) |
| Reinjury | 12 (24.5) | 49 (52.7) | 91 (54.8) | 54 (47.4) | ||||
| Layoff time, d, median (IQR) | 21 (10- 38) | 21 (10-32) | 14 (10-28) | 21 (14-45) | 12.46 c | .006 | – | |
| Severity degree | Minimal | 2 (4.1) | 0 (0.0) | 2 (1.2) | 0 (0.0) | 17.57 b | .04 | 0.118 (weak) |
| Mild | 5 (10.2) | 13 (14.0) | 21 (12.7) | 10 (8.8) | ||||
| Moderate Severe |
28 (57.1) | 56 (60.2) | 114 (68.7) | 66 (57.9) | ||||
| 14 (28.6) | 24 (25.8) | 29 (17.5) | 38 (33.3) | |||||
Data are presented as n (%) unless otherwise indicated.
Chi-square test.
Kruskal-Wallis test.
Table 5.
Adjusted Residuals for Injury profile by Playing Position a
| Goalkeeper | Defender | Midfielder | Forward | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Injury type | Bone | –1.40 | NS | 0.10 | NS | 0.80 | NS | 0.00 | NS |
| Joint/ligament | 0.40 | NS | 0.20 | NS | 0.00 | NS | –0.50 | NS | |
| Muscle/tendon | –2.80 | HS | 0.10 | NS | 0.30 | NS | 1.60 | NS | |
| Soft tissue | 5.20 | HS | –0.10 | NS | –1.80 | NS | –1.60 | NS | |
| Central/peripheral nervous system | 3.10 | HS | –0.80 | NS | –0.40 | NS | –1.10 | NS | |
| Injury anatomical site | Upper limb | 7.20 | HS | –2.80 | HS | –2.20 | S | –0.20 | NS |
| Lower limb | –9.00 | HS | 2.30 | S | 2.90 | HS | 1.20 | NS | |
| Trunk | 0.10 | NS | –0.70 | NS | –0.80 | NS | 1.50 | NS | |
| Head | 4.90 | HS | 0.10 | NS | –1.30 | NS | –2.10 | S | |
| Mechanism of injury | Blow | 2.60 | HS | 0.60 | NS | –1.20 | NS | –1.20 | NS |
| Overstretch | –3.10 | HS | –0.80 | NS | 2.40 | S | 0.40 | NS | |
| Twisting | –3.70 | HS | 0.40 | NS | 1.30 | NS | 0.90 | NS | |
| Fall | 3.80 | HS | –1.50 | NS | –1.80 | NS | 0.70 | NS | |
| Overuse | 2.40 | HS | 1.10 | NS | –1.70 | NS | –0.90 | NS | |
| Context | Training | 3.60 | HS | –0.80 | NS | –2.00 | S | 0.40 | NS |
| Match | –3.60 | HS | 0.80 | NS | 2.00 | S | –0.40 | NS | |
| Classification | First time | 4.00 | HS | –0.10 | NS | 1.00 | NS | 1.90 | NS |
| Reinjury | –4.00 | HS | 0.10 | NS | –1.00 | NS | –1.90 | NS | |
| Severity degree | Minimal | 2.40 | S | –1.10 | NS | 0.40 | NS | –1.20 | NS |
| Mild | –0.30 | NS | 0.80 | NS | 0.50 | NS | –1.10 | NS | |
| Moderate | –0.80 | NS | –0.50 | NS | 2.10 | S | –1.20 | NS | |
| Severe | 0.60 | NS | 0.20 | NS | –2.80 | HS | 2.40 | S | |
Adjusted residual > 1.96 (S) > 2.58 (HS). Positive residual = observed > expected; negative residual = observed < expected. Values in bold indicate statistical significance. HS, highly significant; Nonsignificant, NS; S, significant.
The upper limb was the most affected site for goalkeepers (44.9%; n = 22), while the lower limb predominated for all outfield positions. A significant, moderate association existed between position and injury site (χ2 = 93.6; P < .001; Cramér V = 0.27) (Table 4). Goalkeepers had significantly more upper limb and head injuries and fewer lower limb injuries than expected. Defenders and midfielders had more lower limb injuries than expected, while forwards had fewer head injuries than expected (Table 5).
Injury mechanism also varied significantly by position (χ2 = 48.1; P < .001; Cramér V = 0.19). The most common mechanism for goalkeepers was blows (36.7%; n = 18); for defenders and attackers it was twisting (30.1% and 31.6%, respectively); and for midfielders it was overstretching (33.1%; n = 55) (Table 4). Goalkeepers had significantly more injuries from blows, falls, and overuse and fewer from overstretching and twisting than expected. Midfielders had more overstretch injuries than expected, while defenders and forwards showed expected distribution across mechanisms (Table 5).
Goalkeepers sustained a significantly higher proportion of training injuries (75.5%; n = 37), whereas midfielders and forwards had more match injuries (54.2% and 58.8%, respectively). Significant positional differences were observed for injury context (χ2 = 17.2; P = .001) (Tables 4 and 5).
First-time injuries were notably more frequent among goalkeepers (75.5%; n = 37) and in forwards (52.6%; n = 60). In contrast, injuries in defenders and midfielders were more commonly reinjuries (52.7% and 54.8%, respectively). Significant positional differences were observed for injury classification (χ2 = 14.7; P = .002) (Tables 4 and 5).
Injury layoff time differed by position (P = .006) (Table 4), with midfielder injuries resulting in significantly shorter layoffs than forward injuries (P < .001).
Moderate injuries were most common across all positions. A significant, weak association was found between position and injury severity (χ2 = 17.6; P = .04; Cramér V = 0.12) (Table 4). Goalkeepers had more minimal injuries than expected, midfielders had more moderate injuries, and forwards had more severe injuries than expected (Table 5)
Diagnostic Modalities by Tactical Position
The most used diagnostic tool for goalkeepers was CT (25.0%; n = 14), while clinical assessment was most frequent for outfield positions. A significant, moderate association was found between position and diagnostic modality (χ2 = 51.2; P < .001; Cramér V = 0.20) (Table 6). Diagnosis of goalkeeper injuries relied more on PXR and US and less on clinical assessment than expected. Diagnosis of midfielder injuries relied more than expected on clinical assessment and less on PXR. Diagnosis of forward injuries relied less than expected on US. Defenders showed no significant deviation in diagnostic modality used (Table 6).
Table 6.
Comparison of Diagnostic Modalities by Playing Position, Including Post Hoc Adjusted Residuals a
| Goalkeeper | Defender | Midfielder | Forward | Test Value | P | Cramér V Test |
||
|---|---|---|---|---|---|---|---|---|
| n = 56 | n = 95 | n = 172 | n = 118 | |||||
| Diagnostic modality |
||||||||
| Clinical | 8 (14.3) | 31 (32.6) | 76 (44.2) | 44 (37.3) | 51.19 b | <.001 | 0.197 (moderate) |
|
| PXR | 10 (17.9) | 23 (24.2) | 49 (28.5) | 33 (28.0) | ||||
| US | 11 (19.6) | 21 (22.1) | 27 (15.7) | 19 (16.1) | ||||
| CT | 14 (25.0) | 8 (8.4) | 11 (6.4) | 4 (3.4) | ||||
| MRI | 13 (23.2) | 12 (12.6) | 9 (5.2) | 18 (15.3) | ||||
| Adjusted residuals analysis | ||||||||
| Goalkeepers | Defenders | Midfielders | Forwards | |||||
| Clinical | –3.6 | HS | –0.8 | NS | 2.80 | HS | 0.30 | NS |
| PXR | 2.8 | HS | 0.30 | NS | –3.40 | HS | 1.40 | NS |
| US | 4.8 | HS | 0.00 | NS | –1.20 | NS | –2.30 | S |
| CT | –1.5 | NS | –0.50 | NS | 0.90 | NS | 0.50 | NS |
| MRI | 0.4 | NS | 1.30 | NS | –0.90 | NS | –0.50 | NS |
Data are presented as n (%). Adjusted residual > 1.96 (S) > 2.58 (HS). Positive residual = observed > expected; negative residual = observed < expected. Values in bold indicate statistical significance. CT, computed tomography; HS, highly significant; MRI, magnetic resonance imaging; NS, nonsignificant; PXR, plain radiography; S, significant; US, ultrasound.
Chi-square test.
Discussion
The major findings of this study demonstrated that the overall injury incidence was 2.36 per 1000 player-hours, with muscle/tendon injuries being most common and the thigh the most frequently injured site. No significant positional difference in overall injury risk was observed. However, position-specific injury profiles varied significantly: Goalkeepers showed higher than expected frequencies of nervous system and soft tissue injuries, upper limb and head involvement, and contact mechanisms such as blows and falls, while noncontact mechanisms were less common. Goalkeepers also had higher than expected numbers of training-related and first-time injuries, as well as minimal injuries. Midfielders had higher than expected numbers of injuries due to overstretching and match-related injuries resulting in shorter absences compared with forwards. Forwards had higher than expected frequency of severe injuries. Defenders were taller and heavier than midfielders and forwards.
This study provides the first prospective analysis of position-specific injuries in Egyptian professional soccer. The overall injury incidence (2.36/1000 player-hours) was lower than rates reported in European and South American studies.5,15,18 This difference may relate to the exclusive inclusion of time-loss injuries with omission of injuries requiring medical attention. Also, this difference could be explained by potential injury underreporting within the Egyptian context and early return-to-play practices influenced by economic pressures.
The injury pattern in this cohort was characterized by a predominance of muscle and tendon injuries followed by joint and ligament injuries. The lower limb was the most frequently affected site, with the thigh being the most common location. These findings align with the global soccer epidemiology.5,8,9,19 Injuries occurred slightly more often via noncontact traumatic mechanisms and during matches and were slightly more often first-time occurrences. The mean layoff time was 21 days, with moderate injuries being most prevalent. These findings align with those of Forsythe et al, 5 who reported that 51.1% of injuries occurred during matches and that the mean absence due to medical attention injuries was 15.8 days. The most frequent diagnostic tool was clinical assessment followed by PXR.
Our study demonstrated no significant positional difference in the overall risk of injury (P = .07) despite the detected difference in exposure time (P = .007). Any concern that differing exposure times might mask the true injury risk was addressed by the calculation of standardized injury incidence (per 1000 player-hours), a measure that accounts for varying exposure time. This finding is in accordance with previous studies examining injuries in American Major League Soccer 11 and the English Premier League, 7 which demonstrated no influence of playing position on the injury occurrence.
Our study also demonstrated variations in player characteristics according to playing position. Goalkeepers had significantly greater height, body mass, and BMI than outfield players, particularly forwards (all P < .001). This physical profile is expected, as height and mass are advantageous for goalkeepers, who require aerial coverage and robustness against collisions. 17
In addition, the study demonstrated variations in injury profile according to playing position. Goalkeepers’ injury profile was distinct. They had a higher than expected frequency of nervous system and soft tissue injuries, greater involvement of the upper limb and head, and a predominance of contact mechanisms such as blows and falls (all adjusted residual >2.58; highly significant). In contrast, noncontact mechanisms like twisting and overstretching were less common (negative adjusted residual < –1.96). This unique injury profile reflects the role-specific exposures as they face aerial collisions and landings. This finding is consistent with other professional leagues, where goalkeepers had more upper limb and contact-related injuries.7,10,17
The observed goalkeeper injuries occurred at a higher than expected rate during training and were more often first-time injuries (all adjusted residual >2.58; highly significant). Also, they were more likely to be minimal injuries (adjusted residual >1.96; significant). These findings may be explained by the unique exposure pattern of goalkeepers during training. All goalkeepers within the squad, including the first choice and backup goalkeepers are actively involved in training. However, only 1 goalkeeper participates during matches. Consequently, the cumulative training exposure of a goalkeepers group is disproportionately higher than their match exposure. In addition, goalkeeper-specific training typically involves high volumes of repetitive diving and landing exercises performed under controlled but frequent exposure conditions. This increases the likelihood of minor traumatic or overload-related injuries. These findings are consistent with other soccer epidemiological studies.3,16,17,19
Observed injuries among outfield players had a higher than expected frequency of lower limb involvement opposed to upper limb and head regions. This reflects the high lower extremity demands of these positions.15,18 Diagnosis of injuries in these positions relied more on clinical assessment than on imaging such as PXR or US. Defenders were taller and heavier than the other 2 outfield positions (P < .001). This physical profile was expected, as height and mass are advantageous for defensive demands of aerial duels and shielding.5,15,18 The observed midfielder injuries occurred at a higher than expected rate by overstretching (adjusted residual >1.96; significant). This reflected their role-specific demands of offensive and defensive plays and the fact that they covered a greater running distance during a game.17,18 Also, they were more likely than expected to occur during a match (adjusted residual >1.96; significant) and resulted in shorter absences compared with forward injuries (P < .001). This could possibly reflect the predominance of match-related muscle strains due to greater running distances.5,18 The observed forward injuries were more likely than expected to be severe injuries (adjusted residual >1.96; significant). Forwards’ reliance on repeated sprints may predispose them to more significant tissue damage.5,18
The study highlights the need for 2 strategies. The first is selection of position-specific rehabilitation according to playing position to minimize the risk of common injuries. The second is the consideration of the player's anthropometric profiling when assigning them, as this may help reduce physical risks from the outset of their careers. While certain basic rehabilitation programs (eg, agility training and safe tackling) may serve multiple playing positions, further program customization to positional demands ensures a comprehensive approach to injury prevention. 17 Examples include upper limb strengthening and landing technique for goalkeepers, regulated training loads and neuromuscular training for midfielders to prevent overstretching injuries, and hamstring-quadriceps balance and sprint mechanics training for forwards to reduce severe lower limb injuries. 14 Similarly, consideration of defenders’ greater height and mass would provide an advantage in aerial duels and ground physical challenges. 14 This targeted approach would reduce injuries and better prepare players across professional teams.
Limitations
Our study has limitations. The playing positions were unequal in terms of their sample sizes, which might limit statistical power for certain positions. However, this distribution reflects the natural composition of soccer teams. External environmental factors, such as ground surface, were not recorded. In addition, the observed difference in diagnostic modality use might reflect health system or physician preference within Egyptian context rather than injury characteristics. Despite these limitations, this is the first analysis to examine the influence of playing position on injury profile among professional soccer players in Egypt from 12 clubs. In addition, our findings were based on inferential statistics, not just descriptive statistics.
Conclusion
Our study showed that injury patterns among Egyptian professional soccer players vary significantly by playing position. While muscle/tendon and lower limb injuries are common overall, the 4 positions exhibit distinct anthropometric, injury mechanism, site, severity, and diagnostic profiles. These findings recommend position-specific injury prevention and rehabilitation in Egyptian professional soccer.
Footnotes
Final revision submitted May 31, 2026; accepted June 2, 2026.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.
Ethical approval for this study was obtained from the research ethics committee of the Faculty of Medicine at Ain Shams University (reference No. FMASU MS 229-2022).
ORCID iDs: Haitham K. Haroun 
https://orcid.org/0000-0002-5466-5601
Mohamed A. Elsayed https://orcid.org/0000-0001-9829-3558
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