What to Know About Soccer Injuries - And How To Prevent Them

By Barry Boden, M.D., The Orthopaedic Center

As we head back-to-school this fall, we know the many benefits of students participating in school sports. Athletics give students of all ages an opportunity to exercise after school and stay fit and healthy. But there is always the risk of injury. In fact, more than 2.6 million athletes under the age of 20 are treated in emergency rooms for injuries as a result of playing sports, according to the Center for Disease Control and Prevention. Since soccer is one of the most popular fall sports, let’s review some of the common injuries that soccer players experience.

Most injuries in soccer occur to the lower extremities

Lower-extremity injuries account for more than 60 percent of all soccer injuries, including muscle strains, contusions and ankle sprains as the most common acute injuries. Soccer players have a high risk of suffering soft tissue injuries to their legs, and shin guards are the only protective devices that are required by most soccer associations. While shin guards are most effective at reducing leg abrasions and contusions, they are inadequate at preventing other serious lower-extremity injuries, such as fractures.

Ankle sprains are extremely common in soccer players

Besides contusions and abrasions, ankle sprains are the most common injury in soccer players. The constant cutting and pivoting in soccer, as well as playing on uneven surfaces, predispose soccer players to ankle sprains. The most common ankle injury is an inversion sprain. In this situation, the foot turns inward, stretching the ligament on the outside of the ankle. Treatment consists of the RICE (rest, ice, compression and elevation) protocol. Following this injury, physical therapy and taping and/or a brace often allow athletes to return to soccer within a few weeks. Ankle injury prevention drills, especially proprioception or balance exercises, can help reduce the risk of a recurrence.

Anterior cruciate ligament (ACL) injuries

Due to the pivoting and cutting nature of soccer, ACL injuries are a frequent problem. Female soccer players have been shown to be at particular risk, with a 2-to-8 fold higher incidence of ACL injuries than their male counterparts. The mechanism of ACL injury usually involves an individual running with the soccer ball or covering the person with the soccer ball. A minor perturbation often causes the player to reach forward with the affected leg and land flatfooted while the knee is relatively straight. When landing flat-footed, the calf muscles are unable to absorb the impact force with the ground, which is transmitted to the knee and may cause ACL disruption. 

However, preliminary results reveal that ACL prevention programs can be effective. These programs combine stretching, plyometrics, agility drills and weight training. The focus of the programs is to teach athletes to land on their toes with the knees flexed (bent) and the chest over the knees. The PEP (prevention injury enhance performance) ACL prevention program was developed by the United States Soccer Federation and can be incorporated into warm-up drills during soccer practices. The drills are geared towards avoiding vulnerable knee and ankle positions that may lead to ACL injuries. An example of such a drill would be having athletes jump back and forth over a soccer ball for 30 seconds. In this exercise, the athletes are encouraged to land on the balls of their feet, with the knees bent in a crouching position. The knees should never be allowed to buckle inward toward the opposite knee, a frequent tendency during fatigue. 

Heading the soccer ball

Considerable debate exists about whether heading the soccer ball is dangerous. It has been demonstrated that the soccer ball impact is well below that necessary to produce a concussion. In fact, a soccer ball would need to travel at 40 miles per hour to cause a concussion. A soccer ball descending from a punt typically travels at a maximum of 30 miles per hour. While it is unlikely that brain damage can occur from a single heading episode, it is possible that repetitive heading may lead to long-term sequelae. Long-term prospective studies are necessary to answer this question, but it is prudent to understand the risks.

Although heading appears to be safe, several precautionary measures should be followed to lower any potential risk of head injury. Teaching proper heading skills is important, as players should strike the ball on the forehead with the cervical muscles tensed, and should not allow the ball to strike the head while unprepared. At the youth level, heading drills should be avoided until the effects of repetitive heading are better understood. Smaller soccer balls, size 3 and 4, are used during practice and game situations for youth players instead of the adult size 5 ball to reduce the risk of a potential head impact in younger players. 

Concussions

Concussions are a frequent injury in soccer and usually occur from head-to-head collisions or head contact with an opponent or the ground. It is rare that a concussion is caused by contact with the soccer ball. Dangerous situations for concussions include the penalty area, game play, small fields and as a result of a referee who allows rough play. The “back-flick” is a unique soccer play that places the defensive player at risk for injury, in which the back of the offensive player’s head may inadvertently collide with a closely positioned defensive player’s face or head, often resulting in a concussion. Coaches need to become more aware of the symptoms of a concussion and should never allow an athlete with a suspected concussion to return to play without being assessed by medical personnel.

While it is widely accepted that the health and social benefits of team sports outweigh the risks, it’s critical to understand common injuries and warning signs, as well as treatment and prevention. By educating players, parents and coaches, and encouraging safe play, players can often prevent these common soccer injuries.

Barry Boden, M.D., specializes in sports medicine at The Orthopaedic Center division in Rockville and Germantown, Maryland. He provides complete care for athletes of all ages and specializes in shoulder and knee conditions, offering non-operative treatment and state-of-the-art arthroscopic surgery techniques. Dr. Boden is the team physician for the athletes at Montgomery College and has served on the medical staff for U.S. Soccer and DC United. He also serves as a consultant at the NIH and a professor at the Uniformed Services University of the Health Sciences. 

REFERENCES

Boden BP, Kirkendall D, Garrett WE: Concussions in Elite College Soccer Players. Amer J of Sports Med, 25(2):238-241, 1998.

1. Boden BP: Leg Injuries and Shin Guards. Clinics in Sports Medicine, 17(4)769-777, 1998.
2. Boden BP, Lohnes JJ, Nunley JA, Garrett WB: Tibia and Fibula Fractures in Soccer Players. Knee Surgery, Sports Traumatology, Arthroscopy, 7(4):262-266, 1999.
3. Boden BP, Sheehan FT, Torg JS, Hewett TE. Noncontact Anterior Cruciate Ligament Injuries: Mechanisms and Risk Factors. J Am Acad Ortho Surg, 18:520-527, 2010.
4. PEP Program: Holly Silvers, MPT Hollypt99@aol.com 310-315-0292 ext. 1283.