Hamstring Injuries: A Paradigm for Return to Play.

Muscle injuries are the most common sports-related injuries, with hamstring involvement most common in professional athletes. These injuries can lead to significant time lost from play and have a high risk of reinjury. We review the anatomy, mechanisms of injury, diagnostic imaging modalities, and treatment techniques for hamstring injuries. We also present the latest evidence related to return to play (RTP) after hamstring injuries, including a review of articles targeted to RTP in European soccer (Union of European Football Associations), American football (National Football League), and other professional sports. Review of imaging findings in hamstring injury, grading systems for injuries, considerations for RTP, as well as advances in injury prevention, are discussed.

Osseous Stress Injuries: Treatment Algorithms and Return to Play.

Osseous stress injuries are common in athletes. Specifically, lower extremity injuries are prevalent in running athletes and upper extremity injuries are prevalent in throwing athletes. Such injuries are suspected when there is focal bone tenderness and increased pain with the inciting activity. In elite athletes, osseous stress injuries are a relatively common culprit in lost play time. Thus rapid diagnosis and treatment is imperative to expedite return to play (RTP). The radiologist's role in these cases is not only for diagnosis, but also to grade the injury, which has implications in determining a treatment regimen. The high sensitivity and specificity of magnetic resonance imaging is thus the preferred imaging modality. This article discusses common osseous stress injuries, the imaging findings, and how different treatment regimens affect RTP.

The Order of Operative Repair Does Not Influence Outcomes in Patients with Concomitant Popliteal Artery and Orthopedic Injuries.

BACKGROUND: The most challenging lower extremity traumatic injuries involve concomitant vascular and orthopedic injuries with amputation rates approaching 50%. Controversy exists as to how to prioritize the vascular and orthopedic repairs. We reviewed patients with popliteal artery and lower extremity orthopedic injuries to analyze the sequence of the vascular and orthopedic repairs on outcomes. METHODS: All adult patients with a diagnosis of concomitant popliteal artery and lower extremity fracture or dislocation were identified through a review of an institutional trauma registry performed at a level 1 trauma center from 2014 to 2019. Patient demographics, timing of presentation, injury severity score (ISS), surgical interventions, and limb outcome data were collected and examined. The sequence of operative repairs and factors influencing the operative order were analyzed. RESULTS: Twenty-nine patients were treated for popliteal artery injuries. Twelve of these 29 patients had concomitant popliteal artery and orthopedic fractures requiring surgical repair. Injury mechanisms included both blunt (50%, 6/12) and penetrating trauma (50%, 6/12); the majority involved femur fractures (58%, 7/12). Vascular repair included arterial bypass (75%, 9/12) or interposition grafts (25%, 3/12). Orthopedic repair included external fixation (83%, 10/12) and open reduction internal fixation (17%, 2/12). Vascular repair was performed first in 7/12 limbs (58%). Patients having vascular repair first had a trend toward lower blood pressure on arrival (P = 0.068). There was no significant difference in emergency department to operating room (OR) time, OR time, ISS, mangled extremity severity score, estimated blood loss, or blood transfusion for the sequence of operative repair. Fasciotomy was nearly ubiquitous, present in 11/12 patients (92%). There were no graft complications related to orthopedic manipulation, and there were no reported limb-length to graft-length discrepancies. Early limb salvage trended lower in the cohort with revascularization first (71% vs. 100%, P = 0.19). Of the remaining limbs available for follow-up, limb salvage at 4.25 years is 100%. CONCLUSIONS: In this small study of patients with concomitant lower extremity popliteal artery and orthopedic injuries, the order of operative repair does not appear to influence the success of revascularization.

Are all hamstring injuries equal? A retrospective analysis of time to return to full training following BAMIC type 'c' and T-junction injuries in professional men's rugby union.

We aimed to determine whether the anatomical location (intramuscular tendon or T-Junction) of hamstring muscle injuries in professional men's rugby union associates with a prolonged time to return to full training and a higher rate of re-injury/subsequent injury. We reviewed the medical records of an Irish professional rugby union club to identify hamstring muscle injuries incurred across five seasons. Clinicians and players were not blinded to MRI results at the time of rehabilitation. A blinded musculoskeletal radiologist re-classified all included injuries (n = 91) according to the British Athletics Muscle Injury Classification framework. Players who sustained an injury with intramuscular tendon involvement required a longer time to return to full training compared to players who sustained an injury without intramuscular tendon involvement (78 days vs. 24 days). Players who sustained a biceps femoris injury with T-junction involvement did not require a longer time to return to full training compared to players who sustained a biceps femoris injury without T-junction involvement (29 days vs. 27 days). Injuries with either intramuscular tendon or T-junction involvement were not associated with an increased rate of re-injury/subsequent injury to the same limb (intramuscular tendon involvement - odds ratio = 0.96, T-junction involvement - odds ratio = 1.03). When a hamstring muscle injury involves the intramuscular tendon, the injured player and stakeholders should be made aware that a longer time to return to full training is likely required. T-junction involvement does not alter the expected clinical course of biceps femoris injuries.

Cost-effectiveness analysis of routine computed tomography angiography (CTA) for lower extremity penetrating trauma.

BACKGROUND: Routine evaluation with CTA for patients with isolated lower extremity penetrating trauma and normal ankle-brachial-indices (ABI) remains controversial. While prior literature has found normal ABI's (≥0.9) and a normal clinical examination to be adequate for safe discharge, there remains concern for missed injuries which could lead to delayed surgical intervention and unnecessary morbidity. Our hypothesis was that routine CTA after isolated lower extremity penetrating trauma with normal ABIs and clinical examination is not cost-effective. METHODS: We performed a decision-analytic model to evaluate the cost-effectiveness of obtaining a CTA routinely compared to clinical observation and ABI evaluation in hemodynamically normal patients with isolated penetrating lower extremity trauma. Our base case was a patient that sustained penetrating lower extremity trauma with normal ABIs that received a CTA in the trauma bay. Costs, probability, and Quality-Adjusted Life Years (QALYs) were generated from published literature. RESULTS: Clinical evaluation only (no CTA) was cost-effective with a cost of $2056.13 and 0.98 QALYs gained compared to routine CTA which had increased costs of $7449.91 and lower QALYs 0.92. Using one-way sensitivity analysis, routine CTA does not become the cost-effective strategy until the cost of a missed injury reaches $210,075.83. CONCLUSIONS: Patients with isolated, penetrating lower extremity trauma with normal ABIs and clinical examination do not warrant routine CTA as there is no benefit with increased costs.

Patients With Preexisting Anxiety and Mood Disorders Are More Likely to Develop Complex Regional Pain Syndrome After Fractures.

BACKGROUND: Complex regional pain syndrome (CRPS) is a multifactorial condition that may affect patients who sustain a fracture in the upper and lower extremities. Prior investigations have formed a foundation for exploring a possible association between psychiatric disorders and the development of CRPS; however, current studies are conflicted regarding the existence and temporality of a relationship between psychiatric disorders and the potential development of CRPS. QUESTIONS/PURPOSES: (1) Are patients with preexisting anxiety and mood disorders (AMDs) at increased risk of receiving a diagnosis of CRPS after upper or lower extremity fractures? (2) Are patients with preexisting AMDs at increased risk of being diagnosed with CRPS after surgical fixation of their fracture? METHODS: A large, retrospective cohort study was conducted using the TriNetX electronic medical record platform, which contains data from more than 100 million patients. This platform gathers data from healthcare organizations in the United States and Europe and collects comprehensive data over time that includes temporality rather than simply the binary presence or absence of conditions. The cohort included 760,595 patients older than 18 years with upper or lower extremity fractures between 2003 and 2022. Included patients had a minimum 1-year follow-up. We defined AMDs as any diagnosis of anxiety, depressive episode or disorder, a manic episode, or bipolar disorder. Patients with polytrauma or concurrent upper and lower extremity fractures were excluded to reduce confounders. CRPS I diagnosis was identified via International Classification of Diseases, Tenth Edition codes. Propensity score matching was performed to balance cohorts based on age, gender, and race. Hazard ratios and Aalen-Johansen cumulative incidence curves for the diagnosis of CRPS were calculated for patients with and without AMD diagnoses before sustaining a fracture. A subanalysis was performed in which we examined individuals in the upper and lower extremity fracture cohorts who underwent surgical treatment. RESULTS: Patients with preexisting AMDs were at a higher risk of experiencing CRPS I than patients without AMDs were (upper extremity: HR 1.8 [95% CI 1.7 to 1.9]; p < 0.01, lower extremity: HR 2.2 [95% CI 2.0 to 2.3]; p < 0.01). Similarly, patients with preexisting AMDs were at higher risk of experiencing CRPS I after fracture fixation than patients without AMDs were (upper extremity: HR 1.3 [95% CI 1.2 to 1.5]; p < 0.01, lower extremity: HR 2.3 [95% CI 2.1 to 2.5]; p < 0.01). CONCLUSION: Awareness of the relationship between AMDs and CRPS I will direct future research about the development of this condition and associated neurologic changes. Additionally, surgeons can address AMDs perioperatively and arrange for the treatment of these AMDs with psychiatrists, neurologists, or social work, as appropriate. Accordingly, patients with AMDs should also be made aware of the inherent risk of CRPS I after an upper or lower extremity fracture to comprehensively educate and care for this at-risk patient population. LEVEL OF EVIDENCE: Level III, therapeutic study.

UEFA Women's Elite Club Injury Study: a prospective study on 1527 injuries over four consecutive seasons 2018/2019 to 2021/2022 reveals thigh muscle injuries to be most common and ACL injuries most burdensome.

OBJECTIVE: Injuries in women's football (soccer) have scarcely been investigated, and no study has been conducted in the highest competitive level involving club teams from different countries. Our aim was to investigate the time-loss injury epidemiology and characteristics among women's elite football players over four seasons. METHODS: 596 players from 15 elite women's teams in Europe were studied prospectively during the 2018/2019 to 2021/2022 seasons (44 team seasons). Medical staff recorded individual player exposure and time-loss injuries. Injury incidence was calculated as the number of injuries per 1000 playing hours and injury burden as the number of days lost per 1000 hours. RESULTS: 1527 injuries were recorded in 463 players with an injury incidence of 6.7 (95% CI 6.4 to 7.0) injuries per 1000 hours and a nearly fourfold higher incidence during match play compared with training (18.4, 95% CI 16.9 to 19.9 vs 4.8, 95% CI 4.5 to 5.1; rate ratio 3.8, 95% CI 3.5 to 4.2). Thigh muscle injuries (hamstrings 12%, 188/1527, and quadriceps 11%, 171/1527) were the most frequent injury, while anterior cruciate ligament (ACL) injury had the highest burden (38.0 days lost per 1000 hours, IQR 29.2-52.1) with median days lost of 292 (IQR 246-334) days. Concussions constituted 3% (47/1527) of all injuries, with more than half of them (55%, 26/47) due to ball-related impact. CONCLUSION: An elite women's football team can expect approximately 35 time-loss injuries per season. Thigh muscle injury was the most common injury and ACL injury had the highest injury burden.

Quality of Life After Lower Leg Reconstruction With the Latissimus Dorsi Free Flap in Pediatric Patients.

BACKGROUND: The latissimus dorsi free flap is a widely used reconstructive technique for complex lower leg defects in the pediatric population due to its reliability and anatomical features. However, the impact of this technique on the postoperative quality of life in children and adolescents, who require appropriate lower extremity function during their developmental period, remains to be analyzed. METHODS: Patients who underwent microsurgical lower leg reconstruction using the latissimus dorsi flap were analyzed retrospectively. The quality of life of these patients was assessed prospectively using the Lower Extremity Functional Scale (LEFS) at a minimum of 18 months after surgical reconstruction. RESULTS: Sixteen pediatric patients who had severe lower extremity injuries and underwent latissimus dorsi free flap reconstruction met the inclusion criteria. The mean follow-up period was 33.9 months (22-64 months). Two patients experienced postoperative complications: one had partial flap necrosis and surgical site infection, while the other developed a surgical site infection. The LEFS scores ranged from 26 to 80, with a mean score of 64.6. Remarkably, 14 of 16 patients achieved LEFS scores consistent with at least the 10th percentile when compared with normative data. Patients with severe associated fractures presented with the lowest scores. CONCLUSIONS: Based on our findings, the latissimus dorsi flap is reaffirmed to be an excellent choice for lower leg reconstruction in the pediatric population. It effectively restores the quality of life in patients who have experienced moderate to severe lower extremity injuries.

Locoregional Flap Reconstruction of the Distal Third of the Leg - What Role Does it Have in a Modern Reconstructive Algorithm?

ABSTRACT: Reconstruction of traumatic defects of the lower third of the leg poses a challenge due to limited locoregional options. Failed coverage can be associated with prolonged hospital stay, infection, loss of function, and unplanned return to surgery. Over the last few decades, free tissue transfer has dominated reconstructive algorithms for such defects; however, locoregional flaps may provide equally effective coverage in select patients. In the wake of the CODID-19 pandemic, locoregional flaps gained more consideration due to limited resources. We present a literature review and discussion of locoregional flaps, with emphasis on the quality and efficacy of these reconstructive modalities compared with free tissue transfer and surgical indications.Soleus flaps, reverse sural flaps, and cutaneous perforator-based flaps are workhorses for small to medium size defects of the distal third of the leg, even in the setting of concomitant orthopedic trauma and exposed vital structures. It is important to consider such alternatives an integral part of the reconstructive algorithm as they can provide durable coverage with a favorable complication profile with less resource utilization. Appropriate patient selection requires consideration of the character of the defect, smoking status, preexisting vascular disease, and the zone of injury.

Ten-Year Follow-Up of Lower Limb Replantation: Objective Evaluation With Gait Analysis.

ABSTRACT: The decision-making process for lower limb replantation involves several critical factors, such as age, comorbidities, ischemia time, type of injury, and psychosocial considerations. Advances in microsurgical techniques have led to a greater focus on enhancing functionality through limb salvage. To improve functional outcomes, it is essential to gain a better understanding of the current challenges in reconstruction and address them in future cases. Objective functional analysis of lower extremity replantation cases holds the potential to guide us in this endeavor. In this report, we present a lower limb replantation case with a 10-year follow-up, including objective functional evaluation with gait analysis.

Comparison of Postoperative Complications in Patients Undergoing Limb Salvage Reconstructive Surgery Based on Estimated Prevalence of Preexisting Peripheral Arterial Disease.

BACKGROUND: Limb salvage after lower extremity (LE) trauma requires optimal blood flow for successful microsurgical reconstruction. Peripheral arterial disease (PAD) decreases LE perfusion, affecting wound healing. Patients who present with LE trauma may have undiagnosed PAD, particularly those with atherosclerotic risk factors. This study assesses outcomes after LE salvage in patients at risk for PAD. METHODS: This retrospective review evaluated patients who underwent LE reconstruction at a level 1 trauma center between 2007 and 2022. Patients with a nontraumatic mechanism of injury, missing postoperative records, and unspecified race were excluded. Demographics, flap characteristics, and postoperative complications were abstracted. The prevalence of LE PAD was calculated using a validated risk assessment tool. RESULTS: At our institution, 285 LE flaps performed on 254 patients were included in the study. Patients were categorized by prevalence of PAD, including 12 (4.7%) with high risk, 45 (17.7%) with intermediate risk, and 197 (77.6%) patients with low risk. The high-risk cohort had higher rates of partial flap necrosis ( P = 0.037), flap loss ( P = 0.006), and amputation ( P < 0.001) compared with the low-risk group. Fewer high-risk patients achieved full ambulation compared with the low-risk ( P = 0.005) cohort. Overall flap survival and limb salvage rates were 94.5% and 96.5%, respectively. Among the intermediate- and high-risk cohorts, only 50.9% of patients received a preoperative vascular assessment, and 3.8% received a vascular surgery consultation. CONCLUSIONS: Peripheral arterial disease represents a reconstructive challenge to microvascular surgeons. Patients with high-risk for PAD had higher rates of partial flap necrosis, flap loss, and amputation. In the setting of trauma, emphasis should be placed on preoperative vascular assessment for patients at risk of having undiagnosed PAD. Prospective studies collecting ankle-brachial index assessments and/or angiography will help validate this study's findings.

The cross-leg free flap: A systematic review of the literature.

BACKGROUND: Free tissue transfer is a mainstay treatment for lower extremity soft tissue injuries. When the traditional cross-leg flap cannot provide enough coverage, a cross-leg free flap (CLFF) is a limb-saving alternative. The aim of this study is to conduct a systematic review of the literature published on the CLFF. METHODS: We conducted a systematic review of articles describing the CLFF, according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Inclusion criteria included articles with primary data on the CLFF. Exclusion criteria included those describing pedicled cross-leg flaps or lacking complete data. Data analysis was performed using SPSS 29.0. RESULTS: Our review included 28 articles encompassing 130 patients who underwent free tissue transfer. Most were male (63.8%) with a mean age of 32.4 years. Latissimus dorsi was the most common flap type (30.0%), followed by vertical rectus myocutaneous (20.0%). Average flap size was 301.8 cm2 , with trauma in the lower third of the leg being the most common indication (73.1%). The contralateral posterior tibialis was the most common recipient artery (84.1%) followed by the anterior tibialis (9.5%). Complications included amputation (1.4%), partial graft loss, thrombosis, hematoma, prolonged pain, nonunion, and seroma; a forest plot was used to illustrate the low overall adverse events rate. Although bivariate analysis identified age, flap size, type, location, and donor site as variables significantly impacting the incidence of complications (p < .05), this was not sustained in a multivariate logistic regression model. CONCLUSION: The CLFF remains an excellent option for limb salvage when a suitable recipient vessel is unavailable. Our review demonstrates 1.4% flap failure and an acceptable complication rate. While most cases in our review describe muscle flaps, we report a complex case of limb salvage using an unusually large anterolateral thigh flap.

Does the type of lower extremity fracture affect long-term opioid usage? A meta-analysis.

INTRODUCTION:  Patients recovering from musculoskeletal trauma have a heightened risk of opioid dependence and misuse, as these medications are typically required for pain management. The purpose of this meta-analysis was to examine the association between fracture type and chronic opioid use following fracture fixation in patients who sustain lower extremity trauma. MATERIALS AND METHODS: A meta-analysis was performed using PubMed and Web of Science to identify articles reporting chronic opioid use in patients recovering from surgery for lower extremity fractures. 732 articles were identified using keyword and MeSH search functions, and 9 met selection criteria. Studies were included in the final analysis if they reported the number of patients who remained on opioids 6 months after surgery for a specific lower extremity fracture (chronic usage). Logistic regressions and descriptive analyses were performed to determine the rate of chronic opioid use within each fracture type and if age, year, country of origin of study, or pre-admission opioid use influenced chronic opioid use following surgery. RESULTS: Bicondylar and unicondylar tibial-plateau fractures had the largest percentage of patients that become chronic opioid users (29.7-35.2%), followed by hip (27.8%), ankle (19.7%), femoral-shaft (18.5%), pilon (17.2%), tibial-shaft (13.8%), and simple ankle fractures (2.8-4.7%).Most opioid-naive samples had significantly lower rates of chronic opioid use after surgery (2-9%, 95% CI) when compared to samples that allowed pre-admission opioid use (13-50%, 95% CI). There were no significant associations between post-operative chronic opioid use and age, year, or country of origin of study. CONCLUSIONS:  Patients with lower extremity fractures have substantial risk of becoming chronic opioid users. Even the lowest rates of chronic opioid use identified in this meta-analysis are higher than those in the general population. It is important that orthopedic surgeons tailor pain-management protocols to decrease opioid usage after lower extremity trauma.

Characterizing Longitudinal Alterations in Postural Control Following Lower Limb Injury in Professional Rugby Union Players.

Assessment of player's postural control following a lower limb injury is of interest to sports medicine practitioners due to its fundamental role in daily tasks and sporting activities. The aim was to longitudinally monitor professional rugby union players' postural control during each phase of the rehabilitation program (acute, middle, and late) following a lower limb injury. Seven male rugby union players (height 1.80 [0.02] m; mass 100.3 [11.4] kg; age 24 [4] y) sustained a time loss, noncontact lower limb injury. Static postural control was assessed via sway path (in meters), and dynamic postural control was assessed via vertical postural stability index. Group differences (P < .05) were reported across the acute, middle, and late phase. Smaller magnitudes of sway path were observed for eyes-open sway path, and for the middle and late phase smaller magnitudes of vertical postural stability index (P < .05) at the end session compared with first session. Whereas larger magnitudes of vertical postural stability index were found between baseline and the last session (P < .05). Large interindividual and intraindividual variation was apparent across the 3 phases of rehabilitation. Postural control improvements were identified during rehabilitation. However, postural control did not return to baseline, with altered kinetics throughout each rehabilitation phase.

The association between lower limb fractures and weight gain in adults: a prospective analysis of body mass index trends.

PURPOSE: Despite understanding the connection between obesity and fracture risk, there is limited research on the implications of lower limb fractures on subsequent changes in body mass index (BMI). Our study aimed to assess the impact of lower limb fractures on BMI alterations over an 18-month period. METHODS: A multi-center, prospective cohort study was conducted between January 2021 to June 2023, involving 494 adults with lower limb fractures. Participants were recruited within 2 weeks post-injury and were assessed for demographics, injury details, and weight at seven distinct time points. By 18 months, the primary outcome was the mean weight gain. RESULTS: The average age of the participants was 39 (± 12.7) with a baseline weight and BMI of 80.4 kg and 27.6, respectively. At the 18-month follow-up, 75% of patients experienced an average weight increase in 4 kg (± 5.39 kg), equating to a BMI rise of 1.39 (± 1.88). Most patients attributed weight changes to their injury, with nearly half expressing distress from their weight change. Only 37% believed that they had resumed their previous activity levels by the final follow-up. Approximately 31% of the patients sought some form of external weight management care in the form of nutritionist advice, training programs, medication and weight management procedures. CONCLUSIONS: Lower limb fractures significantly affect weight gain over an 18-month period, with substantial psychological and physical consequences. Healthcare providers should anticipate potential weight gain post-fracture and incorporate strategies addressing both physical and mental aspects of rehabilitation to enhance recovery outcomes. Early and even immediate weight bearing may play a pivotal role in mitigating weight changes and returning the patient to their previous level of activity. Further detailed studies focusing on different fractures and postoperative interventions are recommended.

Urinary bladder matrix versus dermal regeneration template for lower extremity wound coverage.

PURPOSE: To compare dermal regenerative template (DRT), with and without split-thickness skin-grafting (STSG), and urinary bladder matrix (UBM) for coverage of lower extremity wounds. METHODS: A retrospective review of 56 lower extremity wounds treated with either DRT and STSG (DRT-S) (n = 18), DRT only (n = 17), or UBM only (n = 21). Patient characteristics, comorbidities, American Society of Anesthesiology (ASA) classification, injury characteristics, wound characteristics, use of negative pressure wound therapy, surgical details, postoperative care, and failure of primary wound coverage procedure were documented. RESULTS: The DRT group, compared to the DRT-S group, was older [median difference (MD) 17.4 years, 95% confidence interval (CI) 9.1-25.7; p = 0.0008], more diabetic (proportional difference (PD) 54.2%, CI 21.2-76.1%; p = 0.002), had smaller wounds (MD - 91.0 cm2, CI - 125.0 to - 38.0; p = 0.0008), more infected wounds (PD 49.0%, CI 16.1-71.7%; p = 0.009), a shorter length of stay after coverage (MD - 5.0 days, CI - 29.0 to - 1.0; p = 0.005), and no difference in primary wound coverage failure (41.2% vs. 55.6%; p = 0.50). The UBM group, compared to the DRT group, was younger (MD - 6.8 years; CI - 13.5 to - 0.1; p = 0.04), had fewer patients with an ASA > 2 (PD - 35.0%, CI - 55.2% to - 7.0%; p = 0.02), diabetes (PD - 49.2%, CI - 72.4% to - 17.6%; p = 0.003), and had no difference in primary wound coverage failure (36.4% vs. 41.2%; p = 1.0). Failure of primary wound coverage was found to only be associated with larger wound surface areas (MD 22.0 cm2, CI 4.0-90.0; p = 0.01). CONCLUSIONS: DRT and UBM coverage had similar rates of primary wound coverage failure for lower extremity wounds. LEVEL OF EVIDENCE: Diagnostic, Level III.

Epidemiology of time-loss injuries within an Australian male professional football club: A 5-year prospective observational study of 21,343 player hours.

This study aimed to establish injury incidence rates (IIRs) and burden within an Australian male professional football club (n = 73) and to investigate longitudinal trends across five consecutive seasons (2016/17-2020/21). There was an overall IIR of 9.18 injuries per 1000 hours (h) (95% CI [7.89, 10.47]). The IIR was approximately seven times greater (rate ratio (RR): 6.85; 95% CI [5.13, 9.19]; p < 0.01) in matches (31.29 injuries per 1000 h; 95% CI [25.25, 37.33]) compared to training (4.49 injuries per 1000 h; 95% CI [3.51, 5.47]). The overall injury burden was 254.1 days lost per 1000 h (95% CI [220.9, 292.3]). Compared with the reference 2016/17 season, there were significant increases in minimal (RR: 6.94; 95% CI [1.27, 128.73]) and mild injuries (RR: 3.76; 95% CI [1.21, 16.39]) in season 2017/18 and decreases in moderate (RR: 0.40; 95% CI [0.19, 0.80]) and contact injuries (RR: 0.35; 95% CI [0.12, 0.90]) in season 2019/2020. Time-loss injury is common and represents a major burden in Australian male professional football, with injuries more frequently sustained during matches. Injury prevention practices should specifically be directed towards muscle/tendon and ligament injuries of the lower limb, particularly anterior cruciate ligament, ankle sprain and hamstring strain injuries.