Pattern of sports injury among the junior high school footballers in Dhaka city of Bangladesh

: Globally, football as a sport has recorded the highest rate of injury morbidity compared with other sports due to the high degree of contact between the players. Coaches play an important role in reducing injuries among the players. The objective of this study was to explore the pattern of football-related sports injuries among junior high school footballers in Dhaka, Bangladesh. A descriptive cross-sectional study was conducted between January 2019 to March 2019 in 20 junior high schools in Dhaka Metropolitan city. We observed 368 boys in the age range of 10 to 18 years old. A pre-structured questionnaire was provided to six trained junior physiotherapists to conduct the face-to-face interview with the boys in the school setting. Most students were from middle-income families. The injury prevalence of defenders was the most (157, 42.7%) followed by midfielders (132, 35.94%), forwards (63, 17.1%), and goalkeepers (16, 4.3%). Tackling was the main cause of injury in 21.1% of cases followed by foul play in 19.1% of the cases. In July, there were more injuries (69.0%) and associated muscle strain. Injured footballers did not visit sports physiotherapists as much as they did other health profession and the association was significant. When considering scientific knowledge, students were aware of fitness, flexibility & endurance (25.5%), sports massage (24.5%), the relation of body structure with sports Injury (21.2%), warm-up and/or cool down (19.6%). Based on the study, it was seen that students had no scientific knowledge of sports. As sports is a key activity for school-going children, comprehensive sports injury preventive knowledge is needed for students and sports teachers and coaches. Access to sports physiotherapists is also needed to prevent and manage sports injury at the field level and for rehabilitation.

wide variety of injuries [6]. An estimated 250,000 knee injuries occur at the high school level each year, a rate of 2.98 per 10000 athlete-exposures [7]. The economic costs of sports injuries among high school athletes in North Carolina were estimated to be $9.9 million in medical costs, $44.7 million in human capital costs and $144.6 million in comprehensive costs plus lost quality of life [3].
Football or soccer considered as the world's most popular sport with over 240 million regular participants (Fédération Internationale de Football Association (FIFA), 2008) [8]. As with other sports however, those participating in football are at risk for injury. Football and/ or soccer had the highest injury rate (4.36 injuries per 1,000 high school athletes) followed by wrestling (2.50) compared to the overall injury rate of 2.44 per 1,000 high school athletes [6]. Due to high degree of contact between players football has been recorded as highest rate of injury compare to other sports [7]. Lower extremity injuries accounted more than 50% of injuries, and more than 57% of football injuries resulted from player contact. In terms of the most common injured body part and injury types are knee internal derangements, ankle ligament sprains, upper leg muscle tendon strains, and concussions during football games and practices [8]. The annual incidence of direct catastrophic football injuries was 1.34 per 100,000 high school and college players [9]. Sportsrelated injuries are commonly seen in the emergency department (ED) setting and account for 23% of all injury-related visits with frequent lower extremity involvement [10]. Remarkable rates of cervical spinal cord injuries in USA found among the high school football players [11]. The similar study found, 88% internal derangement of the knee and 47% patellar injuries. 26% of the footballers with ligament injuries had further injury to the involved knee [12].
Although high school sports injuries need to be considered as a significant public health problem and should be approached from a prevention perspective, most previous studies have focused on assessing injuries through simple injury reporting systems or clinical aspects of specific sport injuries. In addition, very few studies have addressed sports injury prevention for high school athletes; those that have focused on limited issues, such as the development of safety rules and the importance of sports equipment. So, this study aimed to assess the pattern of sports injury among the junior high school footballer of Dhaka city of Bangladesh. Thus, the intent of this investigation was to evaluate the health seeking behavior and to understand the pattern of injury among the professional junior high school footballers in Bangladesh.

Materials and methods:
Study population and place of the study: Junior (boys) high school footballers were the study population of this study and those who were interested to give interview after the school hour and who had experiences to play at least one year with the school team. The study was conducted in Dhaka metro-politan city of Bangladesh. Twenty educational institutions were selected from north and south city corporations of Dhaka. Among the 20th schools 13 were selected from south and 7 from north city corporation.

Study design and study duration:
A descriptive cross-sectional study design was adopted in this study from 01 January 2019 to 31 March 2019.

Sampling:
We have purposively selected 50 institutions where game teachers are available and they have the opportunity for organizing games and from us we send a letter for participation in this research study. Among them 20 institutions agreed to participate voluntarily in this study. We interviewed each football team from the selected schools and the average footballer found 18/ school.

Data collection procedure:
After getting written informed consent from junior high school footballers and their teachers, a pretested semi-structured questionnaire was used to collect the data. Six junior physiotherapists were involved in this study to conduct face-to-face interviews. The game teachers also assisted the students in completion of the interview if they faced any confusions. The average time of the interview was 10-15 minutes.
All interview questionnaires were checked for completeness or correctness before the data entry.
Data was then entered, cleaned and edited into the computer using the statistical software SPSS (Version 23).

Data Analysis:
Standard descriptive statistics were used to analyze the injury status of the adolescent school footballers. Sports injuries were presented by age, education, fathers' occupation according to the wealth index.

Result:
In this study we have interviewed a total 368 number of junior high school footballers (Table 1).
Overall, most of the young school footballers (80.4%, n= 296) are from 13-15 years age group and majority of the respondents (38.6%) are from class VIII, 38.9% of their parents are either private employee and/or government employee. Junior high school footballers by their wealth quantile were Middle income group 32.3%, Lower middle-income group 29.1%, High income group 22.6% and Highest income group were 16% respectively and most of them (35.1%) reported that they got injured themselves three times in the past year during their football match or practices.      Table 3). There was also found that students try to take self-medications from pharmacy (22.5%) ( Table 3). Treatment seeking behaviour from both sports physio/sports injury specialist and self/ from home remedies found 13 among the junior high school footballers.
Defenders experienced most of the injuries 42.7% and then midfielders 35.9% (Table 4). The common causes of sports injury found during tackling (21.1%), then while collision (20.8%) and foul play (19.1%) respectively (Table 4). Regarding sports injury related knowledge among the students found that fitness, flexibility & endurance knowledge found more than the others section of the sports science which was reported highest (25.5%) and then sports massage (24.5%) than other knowledge (Table 5).   between May and September and highest was in the month of July (n= 190) ( Figure 2).

Discussion:
More than three-fourth footballer received sports injury by last one year. Which is a crucial public health concern for the nation. Among 368 footballers, majority of there are group between 13-15 3 13 A number of psychological factors associated with injuries in various sports have been concerned, such as anxiety, frustration, depression, low self-esteem, anger, depression, fatigue, insomnia, loss of appetite, disbelief and low coping skills those factors are influencing not return to sports participation. Post-injury are demotivation for lack of confidence and the fear of re-injury [2,14].
Thirty percent of female footballers terminate their careers due to injury [15]. In this study, we revealed that, overall, 13-15 years students who studied in class VIII with middle income status participated more in study. Sport injury rate increases with the level of play (grade in school) like; player age, and experience [7]. The findings of this study are kind of similar to some of the previous studies. We found the lower extremity (knee, ankle and foot) is the highest frequently injured body part among the footballer and almost seventy-seven percent injuries are moderate type of severity including strain, sprain and torn cartilage. The similar findings observed in other studies [12,16].
Injury prevalence based on position of play showed that defenders (157, 42.7%) were mostly affected followed by mid-fielders (132, 35.94%), forwards (63, 17.1%) and goalkeepers (16, 4.3%) as similar findings stated published article [17]. Tackling is the main cause of injury in 21.1% cases followed by foul play in 19.1% cases. July month found the pick (69.0%) level of injury among the twelve months season. Most of the researchers observed that a lower number of athletes consulted by the physiotherapists than physicians where physician managed 47.4% and athletes treated by physiotherapist 39.6% [18] In this study also found the least number visited to physiotherapy and highest numbers to others profession (Table-3). Sports knowledge specially Fitness, flexibility & Endurance (25.5%), sports massage (24.5%), Relation of body structure with sports Injury (21.2%), warm up and/or cool down (19.6%) and found higher compared to Sports gears, taping and rehabilitation protocol (Table-5).
Sport injury rate increases with the level of play (grade in school) like; player age, and experience [19]. The lower extremity (knee and ankle joints) is most frequently injured body part among the footballer and most injuries severity are mild, including contusion, strain and sprain [11,12].
Remarkable rates of cervical spinal cord injuries in USA found among the high school football players [20].
injuries seventy percent were ligament injuries; eighty-eight, internal derangement of the knee; and forty-seven, patellar injuries. Twenty-six per cent of the patients with ligament injuries had further injury to the involved knee [11].
In the current study, we revealed that, Overall, 13-15 years students who studied in class VII and whose fathers involved in service with middle income status were participated more in study compared to others categories. In terms of injury frequency in the past one-year 2018, the most injury frequency were three times. Once and twice also found higher compared to more than three (3+) times. The injury on hip/leg/thigh region found higher than that of others three body parts.
In cases of injury types in body parts, muscle strain experienced in most of the cases while contusion found least percentage on hip/leg/thigh compared to knee/ankle/foot and forearm/wrist/arm. The most of the footballers experienced moderate types of injury which was four to sixteen times higher than severe and mild types of injury severity. In terms of treatment seeking behavior, the most of the students received health care from medical doctors which was three to four times higher than individually pharmacy, orthopedic, neuro-medicine, sports physio and self. The most of the students experienced injury who played defense level one to nine times higher than goal keeper, mid field and forwards position. The most important cause of injury during tackling which was one to eight times higher than Collision, running, stumble/fall, jumping, foul play, twist/turn, contact with ball and kicking/Passing the ball. Fitness, flexibility & Endurance knowledge found more than the others section of the sports science which was the one to ten times higher than relation of body structure with sports Injury, sports gears, warm up and/or cool down, taping, sports massage and rehabilitation protocol respectively. Finally, the numbers injury fluctuated over the year. In January the injury was only (n=3) which gradually increase and pick in July (n=190) finally at the end of the year in December the injury again decreased drastically (n=1).

Conclusion:
The increasing trend of sports injury among the junior high school footballers are the public health concern in Bangladesh. This study found that more than one third of the students received sports injury in the last year. Most of the injuries occurred to forearm, wrist, arm, followed by to Knee, Ankle, Foot. By nature of injury severity majority were moderate type and highest type of injury were reported muscle strain. In treatment seeking behavior most of them visited medical doctor and 22.5% found took treatment from pharmacy. Knowledge on sports science and sports related injuries among the student also found poor. Further research is needed to explore the incidence to prevent sports injury among the junior high school footballers to prevent early drop-out as they might be the future of Bangladesh national football team.

Acknowledgments:
We gratefully acknowledge all the teachers for their unconditional support for this research activity. We also thank all the students those who participated keenly in this study for providing their valuable time by participating in the interviews. Our special thanks to all the data collectors (Physiotherapists) for their hard work in collecting data.

Contributors:
KH, AAB, AH and NY conceived the paper, contributed to the data analysis, and reviewed the final draft for intellectual content. KH and AAB wrote the initial drafts of the manuscript. AAB reviewed multiple drafts of the manuscript for intellectual content. KH, AAB, EA, HBA, AH and NY reviewed the final draft of the manuscript for intellectual content. All co-authors provided editing support in finalizing the manuscript.

Patient consent for publication: Not Required
Ethical approval: Ethical issues were followed strictly during collecting information for the study during completion of Master in Public Health (MPH) program. The study proposal was approved by the Public Health department of State University of Bangladesh (SUB) (Reg. No. ERCSUB -2020-006), under the study Pattern of sports injury among the junior high school footballers in Dhaka city of Bangladesh and the information were given in an easy and local language (Bengali). The respondents were informed clearly that their personal identity would be kept confidential and the data would be used only for study purposes. Then a written informed consent was taken before the interview from the sports teacher of the respective schools and also from the parents of injured students. The respondent was allowed the right to quit the interview at any time before or once the interview has started. Confidentiality was strictly maintained. Neither any drug nor any invasive procedure was applied.