Injury and Health Registries in German Professional Football – Fundament for Collaboration and Improvements in Medical Team Service

Injury and health registries have become essential tools in all disciplines of sports medicine, particularly in professional football, where player health, availability, and performance are closely linked. These registries serve as a foundation for understanding injury patterns, identifying risk factors, and guiding evidence-based prevention strategies. Drawing from established models such as the NCAA (National Collegiate Athletic Association) Injury Surveillance Program, OSTRC (Oslo Sports Trauma Research Center) Health Monitoring programme in Norway and the UEFA (Union of European Football Associations) Injury Study, registries allow for large-scale epidemiological analysis and foster collaboration among medical professionals.

In Germany, various registry initiatives have emerged in recent years, including media-based surveillance systems, sport-specific injury databases, and a dedicated anterior cruciate ligament (ACL) registry. These have yielded valuable insights into injury burden, return-to-play timelines, and long-term career impacts, especially in high-risk populations such as amateur athletes.

The newly introduced ‘Bundesliga Registry’ in Germany’s top professional leagues represents a significant step forward, offering real-time, physician-led data collection and fostering interdisciplinary discussion on injury management. Beyond data analysis, these registries serve as a platform for shared learning and the development of medical guidelines tailored to football-specific challenges. By directly involving team doctors and physiotherapists in the review processes, registry systems help ensure that medical strategies remain both practical and collaborative.

As the landscape of football medicine continues to evolve, injury and health registries will play an increasingly central role in optimizing player care, enhancing prevention, and ultimately supporting the long-term sustainability of the sport. Purpose of this narrative review is therefore to summarize advantages of registers in sports but also to discuss its limitations.

Key Words: Register, Surveillance, Epidemiology, Prevention, Team Sports, Data Analysis 

Registries are considered as an important component of research in a broad range of medical disciplines. Categorized as cohort study they are an observatorial study with strength in their conclusions and scientific worth. Registry studies are well known in medicine and several large-scaled studies, like the Nurses Health Study, identified the influence of different behaviours and risks for diseases (13). These epidemiological studies form the basis of many well-known findings, such as the reduction of diabetes mellitus through lifestyle changes.

Especially in Scandinavian countries several registries in orthopaedic surgery are well established within a timeframe of over 20 years. For example the Swedish and Norwegian Knee Ligament registries could recently report on patients with a 10-year follow-up after focal cartilage lesions (16).

Registries already demonstrated their benefit in epidemiological investigations in different medical disciplines. Also in sports medicine the knowledge based on registry data is necessary for an application of prevention measures (7). Aim of this paper is to report on advantages and limitations of registries in sports medicine and to provide an historical overview of registries and to present the ‘Bundesliga Registry’. 

The aim of the registry work in sports medicine is to improve prevention strategies and enhance player health. In 1992 van Mechelen et al described the sequence of prevention, which is still a foundation for prevention measures in sports medicine (23). At a first step the injury problem with focus on incidence and severity has to be accessed to identify main injury issues with prevention potential. Secondary aetiology and mechanism have to be investigated for knowing typical injury pattern and situations. With this knowledge, that can be demonstrated by “injury surveillance and registries” a adopted preventive measure can be introduced and in a last step this measure should be reevaluated by repeated injury surveillance via registries (23). Based on registries all steps, excluding the introduction of a preventive measure, can be accessed. The International Olympic Committee (IOC) has also recognized the importance of registries and has therefore published a consensus statement on methodology (3). Based on these guidelines and on further well established methods for injury surveillance the lack of standardized definitions could be minimized within the last years (3, 6).
 In general registries in sports medicine typically employ a prospective cohort design, collecting standardized data (e.g. on injuries or illnesses) on athletes over time. Injuries are usually defined according to consensus statements (e.g., time-loss or medical-attention definitions) to ensure comparability across settings (3, 11). Data are often recorded by team medical staff, treating physicians, or directly by athletes through (electronic) case report forms. Standardized classification systems, such as ICD-10 or sport-specific coding frameworks, are applied to categorize injuries and treatments. Many registries also incorporate exposure data (training and match hours) to calculate incidence rates. Patient-reported outcome measures (PROMs) could be integrated to capture the functional and quality-of-life impact. Data are generally stored in centralized, secure databases, allowing for longitudinal follow-up and large-scale epidemiological analyses.

In the evaluation of registers, it is essential to take the underlying context into account. There are several publications from arthroscopic registries covering sports- or football-specific research questions without any sport-specific background (9, 16). However one of the largest ongoing studies in elite sports with clear football-specific background is the UEFA injury study. Several reports on injury pattern and development of injuries during the last 20 years could be observed with this prospective registration of injuries in elite football in Europe (10, 11, 32). 

Despite the advantages of registries, there are also several limitations that need to be discussed in detail. Registries in sports medicine are limited by their observational nature, which precludes causal inference. Incomplete or selective data entry may lead to a reporting bias, particularly if participation is voluntary. Loss to follow-up and missing patient-reported outcomes reduce the validity of longitudinal analyses. Registries often lack detailed individual exposure data, such as training load and match load, which are essential for injury risk modeling. Confounding by indication is a common limitation, as treatment decisions are not randomized. Finally, results may have limited generalizability, if registry populations are restricted to certain sports, levels of play, or healthcare systems.

The overall aim of all stakeholders in sports and sports medicine should be to increase player availability and reduce injury or disease related time-loss days – no matter if coaches, managers, consultants, physiotherapists or team doctors. Based on a analysis in the UEFA Injury Study communication between the medical staff of a football team and the performance/coaching staff was associated to a reduced rate of hamstring injuries. With high grade of communication and discussion on load management the injury burden could be reduced by 4.1 days per 1000 hours (12). Several studies underlined the relevance of injury prevention with a significant correlation between a low number of injuries and higher team ranking position, total points and more scored goals (8, 15). Further injuries and diseases cause high costs in football medicine and are therefore next to time-loss days a relevant aspect in team care (22). All teams in one league or in several similar leagues with same level of play often suffer from similar injuries and injury pattern. While there may be some regional differences muscle injuries will remain the most common injuries and knee injuries, in particular ACL injuries will remain the injuries with longest time-loss (10, 27). Especially within a similar pattern can be described (2). Building up an injury and diseases surveillance program in form of an registry helps all teams to understand injury focuses and identify specific risk factors. Further a detailed time-loss for the league, with mostly similar medical circumstances can be reported. However building up such a network also offers the possibility to bring experts in sports medicine and team care together. Most of the team physicians work already several years with their teams and developed individual strategies, but sharing these with other colleagues is uncommon. Surveillance programs offer here the possibility to build up space for exchange between colleagues while analysing the overall dataset, but also to collaborate on guidelines based on registry data. Best example here are guidelines based on the work of the National Collegiate Athletic Association (NCAA) in the United States. The NCAA injury surveillance program (ISP) collects since 1982 time-loss incidents in 15 different college sports. Between the stakeholders and doctors several consensus statements and guidelines on e.g. mental health, concussion or diet were published within the last years (4, 17, 31). 

In Germany also some registries are existing in professional and amateur football. The good availability of media data and the quality of these data, especially for severe injuries, was the basis for media based injury surveillance in professional football (18, 21). These registry data could be used to demonstrate no increase in injury incidence in Bundesliga after the SARS-CoV-2 related lockdown in professional football (figure 2) (20). Further a registry on sudden cardiac arrests was founded in Germany and reports on this rare but serious disease in football (5). Within the current discussion on concussion, head injuries and headers in football registry with video analysis on header situations and head injuries was introduced and reported detailed epidemiology and critical incidents (19, 30). Another registry is the anterior cruciate ligament (ACL) registry in German sports, which includes since 2014 ACL ruptures in football, basketball, handball and ice hockey in professional and amateur leagues (29). Based on the earlier mentioned “Sequence of Prevention” for example with this registry a focus with high ACL rupture incidences was identified in amateur football (28). This as well as previous knee injuries could be identified as risk factors, and after the injury a long return to play and high rate of career endings was reported (27, 28). Similar results could be identified in handball (26). With the knowledge of these focus injuries or focus populations and risk factors the next step is to identify the aetiology and mechanism. Based on registry data and with the knowledge when an injury occurred an additional video analysis is the best possible solution for detailed reporting of mechanism (1).

With all this knowledge on different injury surveillance protocols in 2022-23 the “Bundesliga Registry for time-loss injuries and diseases” was introduced into professional football. All time-loss incidents in the first and second league were included into this registry. Documentation is performed by team doctors and team physiotherapists in an online surveillance program based on the IOC Consensus statement. For specific injury types, e.g. muscle, knee, ankle, head, specific injury reports are available. Next to injury circumstances and exact diagnosis, the focus lies on the return to play and treatment of football injuries. At the end of each season the aggregated dataset will be analysed and results of specific injury focus groups discussed with experts among the team doctors (figure 3). The aim of this registry is next to a high player availability and prevention progress, also the inclusion of team doctors in reporting and discussing results. Based on the registry data the medical teams can evaluate the current injury situation in the league and in their club, but also analyse the existing prevention measures. In a second step injury risk factors are assessed and with this knowledge a preventive strategy can be planned and introduced. This model incorporates aspects of van Mechelen (23), but also a risk management approach by Fuller (14) and was mentioned by O’Brien et al (2018) and defined as Team-sport Injury Prevention (TIP) cycle (25).

 While in the season 2022-23 the injury and illness registration started in the first and second Bundesliga in male professional football, in the 2023-24 season same surveillance was introduced in female professional football in Germany covering the first and second division.

- Based on the registry work the development of expert groups in the community of sports doctors should be forwarded to transfer the research results to the daily routine
- With registries big data on sport injuries are available. Thereby a development of interpretation between sportsand medicine is possible. The use of artificial intelligence to analyse this data and identify correlations will become the future in registries.
- Inclusion of additional available data on performance (e.g. tracking data) to injury registries for a comprehensive overview and analysis
- “Transparent player” with many medical data and additional performance data possible. However inclusion of data protection according to local laws necessary

Football-specific health and injury registries are indispensable for advancing player care and optimizing team medical strategies. By enabling structured surveillance, interdisciplinary collaboration, and evidence-based guideline development, these registries support sustained improvements in player health, injury prevention, and team performance across professional football leagues.

Conflict of Interest
The authors have no conflict of interest.

Ethical Approval
This narrative review is based solely on previously published data and literature. No new data were collected or analyzed, and therefore ethical approval was not required. All studies and registries referenced in this review obtained ethical approval as stated in the original publications.

Data Availability
No new data were generated or analyzed in this study. All data supporting this review are available from the cited literature.

Injury and health registries have become vital tools in sports medicine, particularly in professional football, by helping identify injury patterns, guide prevention strategies, and improve player care. In Germany, initiatives like the new Bundesliga Registry enable real-time, physician-led data collection and interdisciplinary collaboration, contributing to evidence-based medical practices. This review highlights the benefits and limitations of such registries in advancing football-specific health management.