Mortality in international professional football (soccer): a descriptive study
Dr. Vincent Gouttebargea, Wesley Oomsa, Tijs Tummersa, dr. Han Inklaarb
a
World Footballers’ Union (FIFPro)
Hoofddorp, The Netherlands
b
Dutch Association for Sports Medicine
Bilthoven, The Netherlands
Congresses: none
Funding: none
Conflict of interest: none
Acknowledgments: The authors would like to thank all national professional footballers’
unions and Infostrada Sports for their support in our study.
Corresponding author:
Dr. Vincent Gouttebarge
World Footballers’ Union (FIFPro),
Scorpius 161
2132 LR Hoofddorp, The Netherlands
Email: [email protected]
Telephone: +31621547499
1
Abstract
Objective
The objective of this study was to describe the characteristics of mortalities from 2007 to
2013 in active (during career) and recently retired (post career) professional footballers.
Method
An observational prospective study was conducted. From 2007, the World Footballers’ Union
(FIFPro) and its related national footballers’ unions (more than 70 countries distributed
across all continents) collected descriptive data (football-related, cause…) on mortality of
active (during career) and recently retired (post career before reaching 45 years of age)
professional footballers by means of several official sources.
Results
A total of 214 deaths were recorded among active and recently retired professional
footballers, leading to an overall mortality rate of 0.47 per 1,000 footballers per year. Of the
214 deaths, 183 were recorded among active players and 31 among recently retired players.
Among the active players, 17% of the fatalities were related to football participation. Disease
was the leading cause of death among professional footballers (55%), of which up to 33%
accounted for suspected cardiac pathology. Accidents accounted for 25% of the overall
deaths, and suicide for 11%.
Conclusions
From 2007 to 2013, 214 deaths were recorded among active (during career) and recently
retired (post career) professional footballers. Leading cause of death was disease (55%),
one third of which were accounted for by suspected cardiac pathology, while accidents
accounted for 25% of all deaths, and suicide for 11%. Attention to the predictive validity and
application of heart-related pre-competition medical assessment should be given, and mental
health support should be developed and implemented both during and after a professional
football career to prevent potential suicidal behaviors.
Key Words: mortality, suicide, sudden cardiac death, soccer
2
Introduction
Football (soccer) is known as the most popular sport in the world. It is played by over 250
million people in more than 200 countries, while the number of fans supporting one or more
professional football teams across all continents has recently reached 3.5 billion.1
Consequently, in recent years professional football has enjoyed a growing interest from the
public and media, with players’ lives on and off the pitch being precisely reported on during
their career but also after their retirement from sport.2 A similar level of interest has also been
prevalent in the scientific literature: the exposure to football training and competition as well
as the occurrence of musculoskeletal injuries among professional footballers have been
frequently reported in empirical studies.3-6
In contrast to studies about exposure and injuries, scientific evidence about mental
illness, osteoarthritis, sudden cardiac death (SCD) or suicides are scarce or even lacking
among
professional footballers.7-9
In
contrast,
information
about fatalities among
professional, i.e. elite athletes from other sport disciplines is available in several studies. The
occurrence of sudden death in young athletes aged from 12 to 35 years old has been
estimated at 6 to 36 deaths per 10,000 athletes per year.10,11 In American football, it was
shown that 718 fatalities occurred over a 55-year period (13 annually on average), while
American football was found to be associated with the highest number of nontraumatic sports
deaths in high school- and college athletes.12,13 After retirement from professional sport,
events with tragic outcome are likely to occurred as this period has been recognized as a
critical phase for many athletes.14-17
Despite the anecdotic reports available, especially with regard to suicide, to our
knowledge there have been no international descriptive studies about fatalities in
professional football.18-20 Scientific information about fatalities among players seems
necessary in order to form a basis for further in-depth analyses and to establish patterns of
mortality in professional football. Ultimately, scientific information about fatalities might lead
to future self-awareness in professional football and would seem a necessary first step to
developing and implementing prevention strategies designed to empower the health status of
3
the players. Consequently, the objective of our study was to describe the characteristics
(demographic, geographic, football-related, cause…) of mortalities from 2007 to 2013 in
active (during career) and recently retired (post career) professional footballers.
Methods
Design
An observational prospective study was conducted of all deaths occurring from 2007 up to
2013 among active (during career) and recently retired (post career) professional footballers.
Data collection
From January 2007 to December 2013, the World Footballers’ Union (FIFPro) and its related
continental divisions (covering all countries across all continents through national unions)
collected data on mortality of all active and recently retired professional footballers (union
members and non-union members alike) in the world. Active professional footballers were
defined as those of 18 years of age or older who have been committing significant time to
football training and have been competing at a professional level according to the national
regulation concerned.21 Recently retired professional footballers were defined as those of 45
years of age or younger (the period just after retirement recognized as critical for many
athletes) who had committed significant time to football training and had competed at a
professional level according to the national regulation concerned.21 In our study, we included
former players up to 45 years of age because scientific literature shows that the period just
after retirement from elite i.e. professional sports is especially a critical and difficult period in
the life of any athlete.14,15
Based on official club releases, official media releases and official websites, FIFPro’s
continental divisions (covering all countries across all continents through national unions)
were instructed to retrieve and report in a standardized way the following descriptive data of
any observed death that occurred either in their country, neighboring countries or continent:
date of birth or age, nationality, field position (goalkeeper or field player), career duration,
4
retirement duration (if applicable), date of death, place of death (continent) and cause of
death. Also, for active players, it was noted whether death was directly related to football
participation during training or competition (football-related) or not (non football-related). We
strived to categorize causes of death as traffic accident, suicide, disease or violent crime.
Traffic accident was defined as sudden death following an accident that occurred in traffic
while being a driver or occupant of any vehicle. Suicide referred to sudden death as a result
of taking one’s own life voluntarily and intentionally. Disease involved death following a
pathological condition (including cardiovascular diseases and cancer) in one or more organ
systems with or without previous known or reported symptoms or signs resulting from various
causes such as infection, genetic defect, or environmental stress.21 Violent crime referred to
sudden death as a consequence of a violent act such as shooting, stabbing or poisoning. We
listed death as unclassified/unknown when the cause could not be reliably established.
Data collected through standardized forms were entered in a single database by one
researcher, and 20% of the data entry was randomly checked by a second researcher. Any
disagreements were resolved by consensus. In order to control the retrieved data and
enhance its validity, as well as to avoid potentially missing information, three additional
sources were consulted: (i) Wikipedia database, which is available online as an open
computerized registry of all deaths of notable people, including current and retired
professional footballers, (ii) Google search engine, and (iii) Infostrada Sports which is an
international sports and media company specialized in producing, distributing, publishing and
monetizing sports data.22,23 The present study was exempt from official ethical approval
accordingly to the Tri-Council Policy Statement related to Ethical Conduct for Research
Involving Humans (Canada) and was conducted in accordance with the Declaration of
Helsinki (2013).24
Statistical analyses
All data were tabulated and descriptive data analyses (mean, standard deviation, frequency,
range) for characteristics and for nature, cause and location of death were performed for the
5
whole study period and by calendar year. Overall mortality rate was calculated as the ratio
between number of all deaths during the 7-year period and the estimated total number of
professional footballers in the middle of the 7-year period, and was expressed per 1,000
players per year.25 Based on information provided by FIFPro’s continental divisions (covering
all countries across all continents through national unions), the number of active and recently
retired professional footballers as defined in our study was a constant number of 65,000.
Leading causes of death from 2007 to 2013, overall proportional mortality ratio and specific
mortality rates among professional footballers were computed. Overall proportional mortality
ratio (%) according to cause of death was calculated as the ratio between number of deaths
from a given cause and number of total deaths.25 Specific mortality rates (expressed per
10,000 per year) according to cause of death were calculated as the ratio between number of
deaths with respect to specific cause during the 7-year period and the estimated total
number of professional footballers in the middle of the 7-year period.25 All data analyses
were performed using the statistical software IBM SPSS Statistics 22.0 for Windows.
Results
Descriptive data over the whole study period and by calendar year for characteristics, nature,
cause, and location of observed deaths are presented in table 1. From 2007 to 2013, a total
of 214 deaths was recorded among active and recently retired professional footballers,
leading to an overall mortality rate of 0.47 per 1,000 footballers per year. Fatalities occurred
on average at 30 years old, after a mean football career duration of 12 years. Almost half of
the fatalities occurred in Europe (48%), which is not surprising as nearly 60% of professional
footballers come from the European continent. Of the 214 deaths, 148 were recorded among
active players and 66 among retired players. Among the active players, 17% of the 148
fatalities were related to football participation.
Leading causes of death from 2007 to 2013, overall proportional mortality ratio and
cause-specific rates among professional footballers are presented in table 2. Disease
(cancer, infectious diseases…) was the leading cause of death over the 7-years period
6
among professional footballers (55%), of which up to 33% were accounted for by suspected
cardiac pathology. Accidents accounted for 25% of the overall deaths, professional
footballers being especially involved in road accidents. Suicide accounted for 11% of the
overall deaths.
Discussion
The aim of the study was to describe the characteristics of mortalities from 2007 to 2013 in
active and recently retired professional footballers. A total of 214 deaths were observed (148
among active players and 66 among retired players), leading to an overall mortality rate of
0.47 per 1,000 footballers per year. Among the active players, 17% of the fatalities were
related to football participation. Over the 7-year period, disease was the leading cause of
death among professional footballers (55%), up to 33% of which were accounted for by
suspected cardiac pathology. Accidents (especially road accidents) accounted for 25% of the
overall deaths, and suicide for 11%.
As far as the authors know, the present study is the first international study to describe the
mortality characteristics among professional footballers. Over a 7-year period, we observed a
total of 214 deaths, almost half of which occurred in Europe, which is not surprising since the
number of professional footballers is the highest on that continent. Most of the studies about
mortality have been conducted in the general population rather than among specific young
adult populations such as in professional, i.e. elite athletes, or footballers. Among young
male adults (20 to 40 years old, similar to our study population), a constant 10 to 20 deaths
per 10,000 per year are reported worldwide, which is more than twice as high as the mortality
rate found in our study.26,27 To put our findings in a more accurate perspective, comparison
can be done with other sport-related mortality studies. To our knowledge, only two studies
have explored the death of professional footballers, both conducted in Italian players. In
2005, Belli and Vanacore investigated the mortality between 1960 and 1996 of Italian
footballers active in the three highest leagues.28 A total of 350 deaths were observed over
7
the study period in the set of 24,000 players recruited in their study, leading to an overall
mortality rate to the one found in our study.28 In their study, Belli and Vanacore also found
that the primary cause of fatalities was diseases (cancer 36%; cardiac 22%), followed by
violence (20%).28 In 2007, Taioli studied the mortality of Italian professional footballers active
in the two highest leagues between 1975 and 2003.29 The author found a total of 63 deaths
in that period, the primary cause of fatalities being car accidents.29 In this study, Taioli also
specified the number of deaths per position played in the professional team.29 The author
showed that players who died were less likely to have been a goalkeeper during their career,
which concurs with the findings in our study: taking one’s own life voluntarily and intentionally
was not related to the goalkeeper position on the field (post hoc Chi-square test not
statistically
significant).29
Recently,
Boden
et
al.
(2013) published
a
descriptive
epidemiological study about mortality among college- and high school American football
players.30 The authors identified 243 fatalities (all male) between 1990 and 2010, leading to a
lower overall mortality rate (0.09 – 0.25 per 10,000 athletes per year) than the one found in
our study.30 The most common cause reported for these fatalities among young athletes was
cardiac (41.2%).30 Between 1946 and 2000, top athletes (male and female) involved in the
twentieth century Olympic Games were enrolled in a cohort study about mortality in Poland.31
During the follow-up period (22 up to 32 years), 257 deaths among male Polish athletes were
observed (cause not stated).31 Among former elite athletes, several studies about fatalities
are available in the scientific literature. Lindqvist et al. (2013) explored the mortality of
Swedish former athletes who were involved in power sports (wrestling, Olympic lifting, power
lifting and throwing) between 1980 and 2008.32 A total of 181 deaths were observed (3.0
deaths per 1,000 athletes per year).32 The leading causes of these fatalities were
cardiovascular pathology, malignant diseases, suicide and accidents.32 A study conducted in
Finland among competitive power lifters (suspected to have used anabolic agents) during a
12-year follow-up showed eight deaths observed among 62 athletes (suicide and cardiac
being leading causes), which is relatively higher than the number of mortalities we
observed.33 In our study, the number of observed deaths increased noticeably from 2008 (13
8
deaths) to 2009 (31 deaths), remaining quite constant in the subsequent years. Such an
increase (nearly 250%) can not be attributed to any concrete logical reason and remains
difficult to interpret.
We should point out some limitations and strengths of our study. The strength of our study
relies on the topic covered, namely the mortality of current or recently retired professional
footballers, and on the prospective design applied. In contrast, as in any scientific research,
data collection is a critical process and its validity should be critically reviewed. In our study,
data on the mortality of active and recently retired professional footballers were collected by
FIFPro and its continental divisions. FIFPro and its continental divisions are distributed in all
countries across all continents, representing and monitoring more than 100,000 current and
retired professional footballers. Internationally, it remains doubtful whether the same official
sources and resources are available for all countries, which might have introduced some
bias. To tackle this issue, and in order to control the retrieved data and to avoid potentially
missing information, strategies were adopted through the data check of the international
Wikipedia database and search engine Google, and through the data check conducted by an
international sports and media company specialized in producing, distributing, publishing and
monetizing sports data (Infostrada Sports). However, despite the application of standardized
procedures, the validity of the mortality data in our study might have been affected and it is
not possible to completely exclude a few missing values. In addition, we did not have precise
information about the medical diagnosis of all deaths (caused by disease), which might be
considered as a potential limitation. With regard to the methodological limitations of our
study, and considering that the prospective data collection of all deaths among players
(current and retired) is still ongoing, FIFPro (and its continental divisions) should review
critically how the validity of future data collection (and related analyses) could be improved in
order to avoid any form of bias. A potential improvement of the data validity might be the use
of national or governmental registers (national retirement systems) as it was done in the
study of Taioli among of Italian professional footballers.29
9
To our knowledge, this is the first international study to describe the mortality characteristics
among professional footballers. By enabling patterns of mortality in professional football to be
established, such a descriptive study might form a basis for future self-awareness and
prevention strategies. Of course, these strategies should focus on preventable death. In our
study, we found that disease was the leading cause of death among professional footballers
(55%), up to 33% of which were accounted for by suspected cardiac pathology. In current
players (exclusively), post-hoc analyses showed that disease was also the leading cause of
fatalities (50%), 56% of which were accounted for by suspected cardiac pathology that was
related to football participation in more than 50% of the cases. To prevent sudden cardiac
death (SCD), governing football bodies (FIFA, UEFA, AFC…) have made a heart-related precompetition medical assessment (PCMA; based on the Lausanne recommendations
combined with stress-ECG and/or echocardiography) mandatory for top international and
continental competitions but only recommended to other leagues.34 This is definitely unusual
and difficult to explain to any stakeholder, as the health of any professional footballer,
whether playing in the Champions League or at a lower professional level, should be
optimally protected in the same way according to the latest evidence-based protocols and
criteria. Furthermore, the consistent application of PCMA at the national level in all
professional football clubs remains doubtful.35 In addition, the lack of scientific evidence
concerning the predictive validity of PCMA for SCD has been acknowledged in several
studies, especially the doubtful value of rest- and stress-ECG, as well as the difficulty
involved in its interpretation.36-39 Hopefully, the recent developments about a better
interpretation of the 12-leads rest-ECG in athletes (the so-called ‘Seattle recommendations’)
might contribute to a higher predictive value of PCMA for SCD.40
In our study, suicide accounted for 11% of the overall deaths among professional
footballers. Suicide in professional football, which might occur as a consequence of mental
illness, has been anecdotically reported in the media. However, in contrast to research about
musculoskeletal injuries, scientific studies about mental illness in professional football remain
10
scarce. In a recent study, 25 to 40% of current and retired professional footballers reported
some mental health problems related to anxiety/depression and adverse health behaviors.8
These findings, as well as the results of our study, endorse the importance of developing and
implementing some mental health support both during – and especially after – a professional
football career, with the critical period just after retirement increasing the likelihood of mental
health problems and, in the worst cases, suicide.14,15
Conclusions
The present study described 214 deaths from 2007 to 2013 in professional footballers up to
45 years of age, resulting in a mortality rate of 0.47 per 1,000 footballers per year. Disease
accounted for 33% of the overall deaths, accidents for 25% and suicide for 11%. In players
currently active in professional football, disease was the leading cause of fatalities (50%),
55% of which were accounted for by suspected cardiac pathology that was related to football
participation in more than 50% of the cases. With regard to these findings, a yearly PCMA
should be made mandatory for all professional footballers at all levels of professional football,
and should be carried out by sports cardiologists i.e. physicians experienced in the
interpretation of normal/abnormal ECGs in elite athletes. Also, attention should be directed
towards improving the management of sudden cardiac arrest on the football pitch according
to latest evidence-based guidelines. With regard to suicidal behavior in footballers, mental
health support should be developed and implemented both during and after a professional
football career.
Table titles
Table 1: Number of observed deaths by nature and cause of death, and by calendar year
among active and recently retired professional footballers
Table 2: Leading causes of death from 2007 to 2013 among active and recently retired
professional footballers
11
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15
Table 1: Number of observed deaths by nature and cause of death, and by calendar year
among active and recently retired professional footballers.
2007
2008
2009
2010
2011
2012
2013
6
13
31
40
39
43
42
214
26
27
31
29
31
32
29
30
Career duration (yrs)
9
9
13
14
11
16
15
12
Goalkeeper
1
0
0
1
1
5
0
8
(4%)
Retired
1
0
9
8
13
20
15
66
(31%)
1
1
5
9
2
4
3
25
(16.9%)
Accident
3
5
7
8
11
8
6
48
(22.4%)
Suicide
0
3
5
3
4
4
3
22
(10.3%)
Disease
3
3
14
21
16
27
24
108
(50.5%)
Cardiac
1
0
8
11
6
14
10
50
(23.4%)
Violent crime
0
2
2
5
3
3
2
17
(7.9%)
Unknown
0
0
3
3
5
1
7
19
(8.9%)
Africa
2
3
5
7
5
10
10
42
(19.6%)
Asia
0
0
4
3
5
4
7
23
(10.7%)
Central America
0
0
1
4
2
4
2
13
(6.1%)
Europe
1
7
17
20
16
23
18
102
(47.7%)
North America
0
0
0
2
2
1
0
5
(2.3%)
Oceania
0
0
1
0
1
0
0
2
(0.9%)
South America
3
3
3
4
8
1
5
27
(12.6%)
All deaths
Total
Characteristics
Mean age (yrs)
Nature of death
Football-related*
Cause of death
Continent
* Only for active professional footballers
16
Table 2: Leading causes of death from 2007 to 2013 among active and recently retired
professional footballers.
Rank order
Cause of death
Number
Proportional mortality
Cause-specific death
ratio (%)
rate per 10,000**
1
Disease
108
55.4
2.37
2
Accident
48
24.6
1.05
3
Suicide
22
11.3
0.48
4
Violent crime
17
8.7
0.37
All causes
195*
4.28
* 19 unknown causes excluded; ** population estimation per year at 65,000
17