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9. 4. 2012.

Injury prevention

The essence of sports medicine is the prevention of injuries. To prevent injuries occurring in a certain sport, it is necessary to be sport specific, i.e. to analyze the incidence, type, and localization of injuries as well as the mechanisms behind the injuries in just that sport. The purpose of these thread is to summarize briefly some mechanisms involved in soccer injuries and then discuss various methods of prevention.

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
Muscle tightness
Inadequate rehabilitation
Shin guards
Playing surface
Other factors

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.


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.


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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