| 11.
Soccer Injuries
"When returning to play from a soccer
injury, it is better to come back a week late than a day too early."
An Ounce of Prevention...
Just before Kaka, now of AC Milan, went to Italy, he played for
Sao Paulo in Brazil. Training there one day the team doctor took
me aside and we watched Kaka in training. As he pointed out the
special talent before us he also pointed out how disciplined they
were to develop this young man over the years and how AC Milan
were interested in taking him to Italy. This doctor also showed
me the fitness and medical data they kept for this player from
the time they picked him as a potential star in their youth system.
The club tracked his speed, fitness, body fat, body weight, injuries,
you name it. They kept records of all this data over all those
years because it was important that when Milan bought the contract
for Kaka, that they knew his history and development too. The
point I am trying to make here is that we have the knowledge and
the tools to track the development of young players and to identify
both strong and weak areas as well as injury patterns over time.
Sao Paulo even spent the final year, before sending Kaka to Italy,
training with an emphasis on increasing his body weight to prevent
injury and improve his performance. Even if your son or daughter
is not going to the professional level in this beautiful game,
we can still train professionally to identify weak spots or imbalances
in a player's overall fitness. The end result will be improved
fitness, improved performance, and decreased incidence of soccer
injuries.
Pre-Season Medical
Although not a requirement, a pre-season medical is a great idea
for any player. A thorough pre-season medical will ensure that
players are not entering the season with an injury or with an
injury that is not fully rehabilitated. The pre-season medical
will also determine the general health of the player and should
identify areas or factors that may predispose the player to risk
of injury, or factors requiring rehabilitation or specific fitness
training.
There are various professionals who might play a role in this
process. Your family or sports medicine physician for example
can do a comprehensive physical that covers all the body systems.
A physiotherapist (physical therapist) can perform a detailed
biomechanical assessment and may assess sport specific movements.
An athletic trainer might look at fitness testing, flexibility,
speed testing, anaerobic power, agility testing and program design.
This information is combined to prevent player injury, and to
set a baseline for fitness and sport specific testing measures.
Ideally the pre-season medical check will occur three months
before the start of the season. If your doctor does not do the
medical assessment then a letter should be sent to the doctor
so that there is greater continuity of care for player and professional
alike.
Player Medical Cards
There is a saying in sports medicine that "to be forewarned
is to be forearmed". In other words, be prepared for potential
medical emergencies. Should anything happen, the coach or trainer
should have a medical card for each player so that pertinent facts
of the medical history are known on the spot.
The following is an example of a player medical card that can
be used but most Sport Associations have their own form that parents
and players receive at the beginning of the year or even better,
before the season begins. Note that many Soccer Association medical
cards include a waiver of risk related to the game itself.
Emergency Action Plan
Every team should have an Emergency Action Plan (EAP) that leads
to the prompt arrival of help should an emergency arise.
The EAP should include:
- Who will provide emergency first aid, including the use of
an automatic external defibrillator (AED).
- Who and how emergency medical services will be contacted.
- The address and location of the field of play.
- Location of telephone(s). If a telephone is not always available
then ensure that a cell phone is available and that there is
cell phone coverage in the area.
- Who will monitor non-injured team members during the emergency.
- Know where the player medical cards (and emergency contacts)
are at all times
- Know where the first-aid kit is at all times. Know the contents
of the first-aid kit.
- Any emergency medical devices such as asthma inhalers, EpiPens,
and AEDs
Types of Soccer Injuries
1.6 million soccer injuries resulted in emergency room visits
among players ages 2 to 18. Twice as many boys were admitted to
hospital for their injuries as were girls. Boys had a greater
amount of face, head, and neck injuries, while girls were more
likely to have ankle and knee injuries.
Most soccer injuries occur in games when the players are tired,
especially near the end of the first and second halves. Injury
rates tend to increase as players get older and their level of
play intensifies. Duke University studied soccer injuries and
found that young players in defensive roles were injured more
often than players in offensive roles. Other studies have found
no relationship across player positions and sport injuries. There
are a few different studies that list the type and location of
soccer injuries. I will provide the statistics from Ekstrand:
>
| Type |
|
Area |
|
| Sprain |
29% |
Knee |
20% |
| Overuse |
23% |
Ankle |
17% |
| Contusion |
20% |
Thigh |
14% |
| Strain |
18% |
Groin |
13% |
| Fracture |
4% |
Foot |
12% |
| Dislocation |
2% |
Leg |
12% |
| Others |
4% |
Back |
5% |
Others, including head injury |
7% |
Elite soccer teams often have the luxury of having a team physician,
physiotherapist or athletic trainer. For the teams who do not
have these medical professionals to consult, the coach or parent
might benefit from knowing a few basics, including when to refer
a player for medical assessment.
The Risk of being Female
Overall, female players are twice as likely as boys to
suffer an injury while playing soccer.
One German study followed 143 elite female soccer players after
noting factors such as injury history, body type and weight, and
player position. After one full season they concluded the following:
- Injury rate was the highest for defenders (9.4 injuries per
1,000 hours of play). Possibly this due to the fact that defenders
perform the most backward and lateral movements.
- Injury rates were second highest for attackers (8.4 injuries
per 1,000 hours of play). Attackers generally spend much of
their time sprinting, feinting, falling, diving and jumping.
- Previous ACL (anterior cruciate ligament) injury significantly
increases the risk of another such injury.
- Taller players (greater than 175 cm.) are more likely to
suffer an injury.
- More injuries happened to the dominant leg.
- Increased body weight during the off season may increase
non-contact injury risk during the competitive season.
- 10% of all players developed more than three injuries.
- Injury risk should be assessed on an individual basis. Injury
prone individuals should be identified, individual risk factors
analyzed and acted upon to prevent further injury and loss of
playing time.
Immediate Assessment and Treatment of a Soccer Injury
Care for the injured player begins immediately. Appropriate care
can mean the difference of days or weeks of rehabilitation, and
minimizes the chances of long term disability.
Upon arriving to the injured player the care giver will first
assess whether the player is breathing. If the player is breathing
then there will an airway and circulation. If the player is not
breathing then assessment of the airway follows with assessment
of circulation after that. In emergency medicine and first-aid
the concept is remembered as ABC (Airway; Breathing; Circulation).
Every soccer team should have at least one person who is trained
in First-Aid.
Once emergent and life threatening worries are out of the way
then we can ask "What happened?", "Where were you
hit?", "Where does it hurt?". A scan is made of
the injured area to observe for bleeding, the position of the
injured part, signs of swelling or deformity and comparison with
the opposite side. If the player cannot continue then an assessment
should continue on the sideline to determine the nature and severity
of the injury. At this point the only safe first-aid advice I
can offer without assessing the athlete is the application of
RICE. Please know that RICE alone is not sufficient to rehabilitate
a serious injury, it is only the first line of defense to control
the injury and hasten the healing process.
| Rest |
Rest the injured area, remove the player from
the game. |
| Ice |
Apply ice to the injured part for 20 minutes or until numb.
Do not use heat during
the acute phase of an injury. |
| Compression |
Apply compression bandages to the area to limit swelling.
Do not apply these too
tightly as it can affect circulation. An easy test of circulation
is the Capillary Refill test. After compression is applied,
wait a few minutes then squeeze one of the toenail beds on
the compressed side until it blanches or turns white. Release
the pressure and the nail bed should return to a pink color
within 1-2 seconds of the release.
|
| Elevation |
Elevate the injured area above the level of the heart. |
When to Refer to a Medical Professional
- Obvious deformities that indicate a broken bone
- Player is unable to bear weight
- Severe pain
- Presence of numbness and/or tingling can indicate a nerve
injury.
- Immediate swelling in a joint. When a joint swells within
a few minutes it usually indicates blood in the joint. Bleeding
indicates that something has torn or ruptured and this requires
a medical diagnosis.
- Swelling that lasts more than 6 days. This sign may indicate
ongoing inflammation to the injured area and requires diagnosis.
This is a book on Soccer Safety, not a book on how to rehabilitate
an athlete. This said, I would like to address some of the basics
to assist players, parents and coaches to understand the injury
process and perhaps gain a better appreciation for the answer
to their number one question:
"WHEN CAN I RETURN TO PLAY?"
Of course the answer to this question varies depending on many
factors. The following section on rehabilitation principles may
help identify the stage of healing the athlete is in and this
in turn may give a better indication of when rehabilitation will
be complete.
Rehabilitation Principles
The ultimate goal following a sports injury of any kind
is to achieve symptom free movement and function, allowing the
player to return to sport in the shortest possible time. Rehabilitation
begins immediately after an injury and continues through the phases
of healing, including whether or not surgery is indicated. Rehabilitation
culminates with a return to sport.
Though easier said than done, this process should begin with
a thorough understanding of the diagnosis as well as contributing
factors to the injury. The healing process will require continuous
assessment because living tissues respond and adapt to the stresses
imposed on them. As the athlete progresses, the plan of care and
the rehabilitation goals must be revisited to ensure they are
still appropriate to the individual.
The following table lists the stages of healing of soft tissues
(muscles, tendon, ligaments):
| Phase of Injury |
Time Frames |
Comments |
| Inflammation Phase |
0 - 6 days |
Signs of inflammation are: redness, heat swelling and pain. |
| Repair Phase |
7 - 21 days |
The body produces new connective tissue to fill the wound
and new blood supplies to these tissues. |
| Remodelling Phase |
22 days - 6 weeks |
Scar tissues align and rehabilitation focuses on restoration
of the athlete's strength, range of motion, stamina, speed,
agility and sport specific skills. This phase can last for
a year or more with fractures or more serious injuries. |
Rehabilitation Goals
These goals represent a continuum rather than a need to achieve
one before moving to the next. For example I may move the athlete
into stabilization exercises when full range of motion is not
yet achieved. Also, I may begin with relatively easy agility exercises
before moving to speed work, which is before more difficult agility
tests and exercises.
- Range of Motion
- Stability
- Strength
- Speed
- Agility
- Sport Specific Skills
Resumption of Soccer Following Injury
The player must not return to play in practice or game conditions
until the following criteria have been met:
- The player can run straight without pain; run and turn in
a figure eight without a sign of a limp.
- The player is able to hop and jump in all directions with
control and speed and without pain.
- Should be able to support full weight with the injured part.
The injured part must be able to support weight or stress through
all planes of movement.
- The player should have practiced with the team prior to competition.
- There is no pain, swelling or disability following training.
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