Injury
aetiology
The assessment of etiological factors responsible
for soccer injuries is a necessity for injury prevention. The cause of a soccer
injury is often multifactorial.
Ekstrand(1983) analyzed possible injury mechanisms and the avoidability of
soccer injuries by compiling information from a pre-season examination and
test, a prospective study of injuries, and a training analysis in Swedish
league. Results are shown in table below.
|
Etiology
of injuries
|
|
|
Player
factors
|
|
|
Joint
instability
|
12
|
|
Muscle
tightness
|
11
|
|
Inadequate
rehabilitation
|
17
|
|
Non-training
|
2
|
|
Total
|
42
|
|
Equipment
|
|
|
Shoes
|
13
|
|
Shin
guards
|
4
|
|
Total
|
17
|
|
Playing
surface
|
24
|
|
Rules
|
12
|
|
Other
factors
|
29
|
Injury
prevention
Pre-season
examination
Pre-season examination and testing of soccer
players are valuable in preventing injury. Incorrect training and individual
player factors such as muscle tightness, malalignment, muscle weakness, and
joint instability are related to many soccer injuries. A pre-season examination
provides the opportunity to analyze and correct individual factors predisposing
to injury. It is suggested that a pre-season examination should include a
physical examination as well as measurements of flexibility and muscle
strength.
Physical
examination
It is recommended that a pre-season examination
begins with an enquiry about past injuries and an examination to evaluate
persistent symptoms from past injuries. Since leg injuries dominate in soccer,
the musculoskeletal profile of the lower extremity should be analyzed to
evaluate persistent symptoms after past injuries. Such examination includes the
following.
Ankle
tests
Mechanical
instability can be
evaluated by the drawer test. If there is mechanical instability, ankle taping
is recommended.
Functional
instability, i.e. feeling
of “giving way” and recurrent sprains can be evaluated by stabilometry.
Stabilometry is an objective method for the study of postural control where the
body sway is measured on a force plate. However, a modified Romberg test can
also be used to evaluate functional instability. The player stands on one leg
with the other leg raised and flexed at the knee, the arms folded across the
chest and the eyes closed. The player should be able to stand for 60s without
putting the raised foot to the ground. Correction movements of the standing leg
are allowed. If the player fails to stand for 60s(three attempts are allowed),
he or she is considered to have functional instability and should be
recommended ankle disk training.
Test
of the knee joint
Measurement of range of movement(ROM) and
clinical instability, such as the anterior drawer test of Lachmann test, are
used for the evaluation of sagittal stability.
They can be complemented by objective
measurement by using a laxity tester. A player with an insufficient anterior
cruciate ligament(ACL) knee is usually unable to continue soccer and should be
recommended for a reconstruction of the ACL.
Test
of the hip joint
Coxarthrosis should be excluded by clinical
examination, i.e. analysis of rotation.
Malalignment
test
Screening for malalignments or other possible
biomechanical risk factors for overuse injuries, should be included in the
physical examination. Examples
of malalignments include: pes cavus, pes planus, Q-angle over 20 degrees, limb
length discrepancy, soft heel pads etc. The use of a mirror-box facilitates the
analysis.
Measurement
of ROM
To disclose muscular tightness of the lower
extremity, a pre-season examination should include measurement of six movements
of the lower extremity:
1) Hip
flexion with the knee straight.
2) Hip
extension.
3) Hip
abduction.
4) Knee
flexion lying prone.
5) Ankle
dorsiflexion with the knee straight.
6) Ankle
dorsiflexion with the knee bent.
In the absence of coxarthrosis, gonarthrosis,
and neurologic disease, these movements are thought to be limited by muscles
and ligaments, and to be restricted in the presence of muscular tightness of
the hamstrings, iliopsoas, adductors, rectus femoris, gastrocnemius and soleus.
Commonly used clinical methods of ROM
measurement have a measurement error of 7-10%, and showed that the accuracy of
measurement could be improved(measurement error <2%) by the use of
goniometers and by secure fixation and marking of anatomical landmarks. Players
with muscle tightness are recommended stretching exercises.
Measurement
of muscle strength
The maximal muscle strength of the knee
extensor(quadriceps) and knee flexor(hamstrings) muscles can be measured with
great accuracy by using an isokinetic dynamometer. In the absence of such
devices muscle strength can be evaluated by using functional tests such as the
one-leg-long-jump or vertical jump.
Correction
of training, warming up, cooling down, and stretching techniques
Soccer players are in general less flexible
than non-soccer players of the same age. There is a correlation between muscle
tightness with strains and tendinitis.
The muscle tightness observed in soccer players
is probably correlated to the design of soccer training. In a field study it
was found that the duration of warm-up was adequate but its content was not
optimal. Since 90% of soccer injuries affect the lower extremities, stretching
exercises for the leg muscles(adductors, hamstrings, quadriceps, iliopsoas, and
triceps surae) should be included in the warm-up and cool-down exercises. A
special warm-up program with contract-relax stretching for the legs combined
with a cool-down program after training has been devised. Moller(1985) found
that this program increased ROM by 5-20%. Players with muscle tightness
detected by ROM measurement at pre-season examination, should be recommended
individual stretching exercises as well. Other corrections of training design
are also valuable in reducing injuries. Shooting at goal before warm-up should
be avoided since it increases the risk of muscle strains.
Planning of soccer season is also of
importance. Ekstrand found a correlation between team success and the amount of
training which would seem logical, provided the quality of training is
adequate. They also found a curved relationship between injuries and training;
teams with less than average training showed an increase in the number of
injuries with increased training, probably the result of prolonged exposure. It
was found, however, that teams with more than average training sustain fewer
injuries with increased training, probabl a reflection of the well-known fact
that well-trained athletes sustain fewer injuries. Another important aspect of
the planning of a season is that a high practice – game ratio seems to be
beneficial with a tendency toward better performance with fewer injuries.
Ankle
taping, bracing, and disk training
Ankle sprains are common in soccer, mostly
affecting joints with a previous history of sprain. Several methods for
prevention of ankle sprains have been documented. Based on findings at the
pre-season examination it is recommended that players with mechanical
instability of the ankle joints are selected for taping or bracing and players
with functional instability(FI) are selected for ankle disk training.
Ankle
taping
Prophylactic taping has become one of the main
methods to prevent ankle sprains. The mechanism behind the effect of taping is
not fully understood. It is assumed that external support increases ankle
stability by re-inforcing the ligaments and restricting motions such as extreme
inversion. A neuromuscular reflex mechanism has also been proposed.
Another question to be answered is, who should
be taped, by whom, and by which method? Ekstrand(1983) showed good results by
selecting players with mechanical instability for taping, letting the coach,
trainer, or doctor tape the players before games using a “stirrup and horseshoe
technique” followed by a figure of eight lock around the heel, and let the
players tape themselves before practice sessions using only stirrups and
horseshoes. The reasoning behind this procedure was the finding that match
injuries are twice as common as practice injuries.
Ankle
bracing
Since ankle tapping is expensive and the
technique can be difficult to learn, an alternative to ankle taping would be
valuable for players with mechanical instability. Various functional semi-rigid
ankle braces are available and semi-rigid supports have been found effective in
restricting ankle inversion and reducing the risk of ankle sprain. Some
players, however, may complain of discomfort from the use of ankle braces.
Ankle
disk training
The most common residual disability after ankle
sprain as FI. Tropp(1985) found impaired postural control and pronator muscle
weakness to be correlated to FI. Players with FI are predisposed to recurrent
ankle sprain. Impaired postural control and pronator muscle weakness as well as
the subjective feeling of instability can be improved by co-ordination training
on an ankle disk.
The exercises are performed on an ankle disk,
which is a section of a sphere, the supporting leg being held straight and the
other leg flexed at the knee. The arms should be folded across the chest.
The recommended dose and duration of training
is 5 ming for each leg, 5 days a week, for 10 weeks. In players with a history
of ankle problems, ankle disk training seems to be the method of choice because
it diminishes FI and breaks the vicious circle of recurrent sprain and
subsequent atrophy. After an initial sprain, further ankle disk training is
indicated even if the player is able to return to soccer play, because of the
increased risk of re-injury. This may prevent residual disability and injury
predisposition.
Equipment
The value of optimum equipment in injury
prevention has been stressed. Shin guards, shoes and insoles are important in
soccer. It has been demonstrated that shock-absorbent, anatomically shaped shin
guards, protecting a large area of the lower leg, can prevent injuries to the
shin bone in soccer players. The variety of soccer shoes available is enormous.
When selecting footwear it should be realized that there is interaction between
the foot and the shoe and the playing surface.
High friction between shoe and surface may
produce excessive forces on the knees and ankles; too little friction, however,
may be the reason for slipping, which affects performance negatively and may
cause injuries. Frictional resistance must be held within an optimum range.
Furthermore, it is generally assumed that the
stiffness properties of the playing surface influence the frequency of
injuries. It is assumed that “hard” surfaces are associated with more injuries
than “soft” and “well-cushioned” surfaces. The stiffness properties of a
surface might have an influence on some chronic overuse injuries which account
for about one-third of all soccer injuries. Overuse injuries can be avoided or
reduced by adequate training, gradual adaptation to a new surface, by the use
of appropriate insoles and suitable soccer shoes, and by adapting the movement
to the surface.
Rehabilitation
Incomplete rehabilitation following a sports
injury is a causal factor in the recurrence of sports injuries. In a
prospective study of soccer players Ekstrand(1982) found that 17% of the injuries were
attributable to inadequate rehabilitation. Rehabiliation following a soccer
injury is commonly neglected, yet few injuries sustained by soccer players are
so trivial that no form of rehabilitation is necessary.
A rehabilitation program should be
sports-specific, gradually increasing the stress on the injured leg, and
step-by-step adaptation for the player before return to play. Return to games
and practice should be decided by the doctor and physiotherapist, and a full,
pain-free ROM, the regaining of co-ordination and more than 90% of muscle
strength should be mandatory. In this way, “controlled rehabilitation” can
reduce the number of soccer injuries.
Information
and supervision
Many authors regard lack of information
regarding the causes of sports injuries as a factor in their occurrence and the
provision of information as an important factor in their prevention. In
soccer, information should be given to coaches and players about:
1. The
importance of disciplined play and the risk of serious own-foul injuries
2. The
increased incidence of injury at training camps and how to avoid such injury.
3. The importance
of the use of protective equipment and other individual protective measures.
Furthermore, supervision by doctors and
physiotherapists is an important part of the prophylactic program.
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