Prevalence and burden of health problems in Norwegian top-level referees: A one-season prospective cohort study

Background: Football referees make decisions during straining physical activity and under great pressure. Despite their central role in the game, little is known about referee health, particularly among female referees. Few long-term prospective studies have been reported, and most studies has solely focused on injuries. Aim: To investigate the prevalence and burden of health problems in female and male top-level referees. Study Design: Prospective cohort study. Method: Fifty-five male and female Norwegian top-level referees reported health problems (injuries and illnesses) in preseason and during the 2020 competitive season, using the Oslo Sports Trauma Research Center Questionnaire on Health Problems. When a new health problem which caused absence from training or match was reported, a sports physiotherapist contacted the participant for more details about the health problem. Results: We recorded data for 49 weeks and had a compliance of 98.1%. On average 34% (95% Confidence Interval 31% to 36%) reported a health problem every week during the season; of these 20% (CI 19% to 22%) were substantial health problems. Female referees report more health problems compared to male referees and on-field referees report more health problems compared to assistant referees. Gradual onset injuries were most prevalent and caused most absence from training and matches, whereas illnesses were a small contributor to the overall burden. Injury incidence was 3 injuries (CI 2.5 to 3.5) per athlete year, 12 injuries (CI 7 to 19) per 1000 match hours and 7 injuries (CI 6 to 9) per 1000 training hours. Illness incidence was 1.4 (CI 1.1 to 1.8) per athlete year. Injuries to the legs and feet represented the highest burden of health problems. Conclusion: Top- level referees report a substantial prevalence of health problems in a full season. Overuse/repetitive gradual onset injuries in the lower extremity represent the highest injury burden and specially in female referees.