The basic elements of soccer involve running, turning, jumping, tackling, kicking and heading the ball. The injuries which occur in this sport, as in any other body-contact game, result from direct blows or from indirect mechanisms. The rules of soccer do not permit outfield players to touch or control the ball with their arms or hands and so much of the trauma seen occurs to the lower limbs. The goalkeeper is in a separate category and his injuries tend to be more general, as he is allowed to use his hands and, in addition, his role often calls for him to dive at the feet of players thereby exposing more of his body to potential injury. Because of the international character of soccer, matches are played on widely varying surfaces and in all kinds of climatic conditions.
HEAD AND FACIAL INJURIES
The soccer player is susceptible to direct blows to the head and face from another player or from the ball. Although the regulation football weighs only 15oz (430g) it can travel at high velocity and if it strikes the face or head at close range, injury may result. A player standing 10 yards (9.1m) from the ball facing a free kick is liable to be hit on the face or head by the ball, and some players, if they choose to turn their backs on a free kick, may be struck on the back of the head by the ball. Apart from a direct blow from the ball, poor heading technique may also produce minor injury at the point of contact.
Accidental clashes of heads while jumping to head clear the ball are common and are particularly likely to occur where players are in close contact with each other, for example, in the penalty area for corner kicks or facing goal kicks, throw-ins or free kicks. During the course of play, a player may be kicked on the head by an opponent if he puts his head down too low to head a ball which he should really have kicked. A goalkeeper attempting to punch the ball clear may miss his target and instead strike another player on the head or in the face . The goalkeeper himself can sustain a head injury diving at the feet of an incoming player or going down to collect a low ball. He also may be knocked off-balance near an upright and is therefore liable to strike his head off the post.
The scalp, eyebrows and lips are common sites of head and facial lacerations in soccer. Nosebleeds, nasal fractures, fractured cheekbones and damage to teeth are also seen and are usually due to direct blows from the ball or from another player. Serious injuries of the eye are rare.
In all cases of head injury, concussion is a possibility and every head injury must be regarded as being potentially serious.
SPINAL AND BACK INJURIES
Fortunately, injuries to the cervical spine are not often seen in soccer. However, a player who falls awkwardly on his head and who injures his neck may sustain a possible serious lesion, and should be managed accordingly. There are recorded cases of goalkeepers who suffered fractured cervical vertebrae as a result of diving at players’ feet.
Other spinal injuries
Injuries to the thoracic and lumbar spine are very rare but must be suspected in the case of severe trauma to the back. These usually result from severe kicks.
Soft tissue injuries
Soft tissue injuries of the back occur quite commonly in soccer due to indirect mechanisms such as jumping or twisting, which cause muscular or ligamentous strains, or due to direct trauma such as a blow from another player. The sacro-iliac joint which connects the pelvis with the spinal column may be the site of chronic injury in soccer players due to strain of the ligaments in the region or in association with osteitis pubis, a condition of the pubic bones in the front of the pelvis. Sacro-iliac strain normally presents as low back pain localised to one or other side which has been troubling the player for a time.
Chest injuries in soccer generally involve the ribs, rib cartilages or muscles of the rib-cage. Direct trauma is the most common cause and the goalkeeper is more susceptible than the outfield players. Injuries to the lower ribs may sometimes damage the underlying kidneys. Bruising of the ribs results from a contusion and an x-ray is required to differentiate this from a fracture.
Probably the most common and least serious abdominal injury seen in soccer is when a player is ‘winded’ following a blow to the lower abdomen from the ball or from another player’s boot. The player usually recovers within a few minutes. Rarely, the abdominal organs may be injured. The liver and spleen in the upper abdomen are protected by the lower ribs and muscle, and the kidneys which are situated on the back wall of the abdomen lie beneath the lower posterior ribs. Severe trauma, such as a knee in the back at the angle under the ribs, can cause damage to the kidney. A goalkeeper may be particularly susceptible to this situation in a crowded goalmouth when stretching for a ball, as this part of his body is left relatively unprotected. It is sometimes difficult to distinguish between a severe muscle injury and possible kidney damage, but the presence of blood in the urine indicates that kidney damage has occurred. The muscles of the abdominal wall can be strained when a player tackles an opponent or when he jumps or twists awkwardly. Rarely a footballer may develop a hernia subsequent to stress injury of the lower abdominal muscles.
PELVIS ‘Groin strains’ are a common finding in soccer players but the term may be applied by footballers to a number of different conditions. Strains of the upper attachments of the muscles of the lower limb may be the reason but another condition which can be responsible is osteitis pubis which occurs particularly after football games, or similar exercise involving a lot of hip rotation (Williams, 1978). Tenderness is found over the symphysis pubis.
The male genitalia, near the pelvis, are vulnerable to direct blows and while most injuries resolve without complication, occasionally a haematocoele may develop; this is characterised by increasing pain, swelling and tenderness of the scrotum, due to the internal bleeding. In soccer a player may sustain this injury if, during a tackle, legs get tangled and an opponent’s leg damages the ‘fixed’ scrotum. It may also occur from a direct blow. Players protect their genital regions with the hands when setting a defensive wall against a free kick close to goal.
Injuries to the upper limb account for a small percentage of soccer injuries in general but the goalkeeper is particularly susceptible. Fractures, dislocations and subluxations are usually caused by falling on the outstretched hand, the point of the shoulder or wrist, or from direct trauma. The collar bone (clavicle) may be fractured by a direct kick or by falling on the outstretched hand. Partial dislocation (subluxation) of the acromio-clavicular joint (between the acromion process of the scapula and the collar bone) can resuit from a fall on the point of the shoulder. Goalkeepers are likely to sustain fractures of the hand and fingers. Dislocations of the shoulder and elbow joint are uncommon but dislocation of the finger joints is often seen and is usually caused by a player falling awkwardly on his fingers, or by the ball striking the hand.
Most of the injuries occurring in soccer involve the lower limb.
The commonest fracture seen is probably due to a direct blow to the lower part of the tibia and fibula. In soccer, the practice of’going over the ball’ whereby an opponent strikes a player on the shin with his boot rather than playing the ball is an illegal act. However, it does occur and may result in a fracture. A goalkeeper diving at the feet of an inrushing forward may fall across the player’s legs in such a way as to cause a fracture . Fractures due to indirect mechanisms are also seen. A full-back who turns acutely can catch his foot in the ground and cause damage to his ankle which may involve fracture of the lower end of the fibula. A soccer injury which frequently occurs is that of a sprained ankle in association with a fracture further up the fibula, often due to a foul tackle. Fractures of bones in the feet and of the toes are usually due to direct blows such as another player striking the foot or occasionally from striking a ball which is blocked by an opponent’s foot. Young players are susceptible to fractures of the epiphyses or growing points of the bone.
Superficial injuries to the skin occur frequently in soccer players when the pitch is hard with little grass on it or when the game is played on synthetic grass like Astro-turf. The sliding tackle in soccer in these conditions can result in quite severe ‘grass burns’ or ‘Astro-burns’.
Muscle injuries of the thigh involve the quadriceps group (on the front of the thigh), the hamstring group (on the back of the thigh) and the adductor group (on the inside of the thigh). Muscle strains of the quadriceps group occur most commonly during the kicking movement but also in sprinting and in overstretching for the ball. This type of injury is often seen in the early part of the season where too much kicking is done with poorly conditioned muscles. More severe types of muscle strain in this region are rupture of muscle or herniation of muscle, usually due to excessive strain.
Muscles of the ‘hamstring’ group tend to be damaged during sprinting and overstretching, and also in kicking. Hamstring strains are encountered throughout the year but appear to be particularly common when conditions underfoot are soft. Injuries to the long muscles of the adductor group are less common but usually are caused by a player overstretching for the ball. It should be emphasised that many of these muscle injuries can occur just as frequently in training as in match situations. While most muscle strains are limited to tears of the fibres, in some cases the origin or insertion of a muscle may be detached and a fragment of bone avulsed at the site of the attachment. In children these injuries may be severe.
Direct blows to the thigh, particularly from the foot or knee of another player are another prevalent injury. Painful bleeding in the tissues can result in haematoma formation and the condition known as ‘charley-horse’ or ‘dead leg’ may be sufficiently uncomfortable as to prevent a player from taking further part in a match.
A complication of a thigh muscle injury, particularly after a direct blow, is myositis ossificans in which part of the muscle tissue becomes ossified.
The knee joint is susceptible in soccer not only to direct trauma but also because stresses and strains of the knee joint mechanisms occur during the game. The main bone of the lower leg, the tibia, is fixed on the ground by the studs of the football boot. It is unable, therefore, to rotate outwards on forced extension or to rotate inwards on forced flexion with the bodyweight in motion. It is consequently vulnerable when subjected to sudden external violence.
Injuries to the cartilages of the knee are usually caused by a combination of rotatory movement and compression (Smillie, 1970). If, for example, the foot is fixed to the ground, and an adduction strain is superimposed, the cartilage may tear because of pressure from the lower part of the thigh bone, I.e. from the medial femoral condyle. Rotation strains on the knee, seen when a player turns quickly, may be of such severity that the cartilage is unable to absorb the stress and it tears. The player therefore who turns sharply on the fixed foot while weight-bearing and who subsequently complains of pain in his knee may have damaged a cartilage. Symptoms such as collapse and locking of the joint may be further evidence of a cartilage injury.
The collateral ligaments on each side of the knee give stability to the joint. When the leg is stretched, e.g. in tackling, the joint is extended and these ligaments are more vulnerable to injury. An opponent striking or falling against the outstretched leg of a player can cause such severe strain to the joint that the ligament on the opposite side of the same knee may be torn. If a player’s foot is ‘fixed’ in a tangle of legs he may fall to one side producing a similar mechanism which can damage the ligament. When a player goes with another for a ‘50/50’ ball and the stresses transmitted up the leg on contact are of sufficient intensity, the knee ligaments may be damaged.
Less serious injuries occur when a rotatory strain affects the knee when it is slightly flexed. The twisting injury can happen, of course, when the player is not weight-bearing. The lateral ligament on the outside of the knee is relaxed when the knee is flexed and is therefore not subject to rotation strains. It is likely to tear when the knee is exposed to sudden and powerful inward movement of the lower leg relative to the thigh.
Within the knee joint are two small ligaments, the cruciate ligaments. The anterior cruciate ligament can be torn when a player who, in the process of heading the ball, is knocked off balance while jumping in the air and falls to the ground with his leg twisted under him. This ligament is often damaged when the medial cartilage is torn. The posterior cruciate ligament may tear when a force of sufficient magnitude is directed against the flexed knee striking the upper front part of the tibia and driving it backwards. If a goalkeeper’s body strikes the lower leg of an inrushing player in such a way as to produce the necessary force, this injury can result.
The patella or knee cap is seldom fractured in soccer but it may be dislocated if a player receives a kick to the inside border of the patella.
Calf muscle injuries
Direct blows from a player’s boot are common but the muscle can be strained when, for example, a player is jumping. Unfit players appear to be more prone to this type of injury. Cramp is a condition where the calf muscles go into spasm and it is seen usually towards the end of games and in unfit players.
Achilles tendon injuries
A kick to the tendon can produce painful tenderness and swelling. Indirect injuries range from partial or complete rupture (usually due to an explosive movement) to inflammation of either the tendon or the surrounding tissues which may become chronic.
Direct trauma to the ankle joint is common largely because of the nature of the game. Inversion injuries of the ankle joint, however, are also common and result in damage to the ligaments on the outside of the ankle. Classically a player who lands awkwardly on his ankle or who, while running, ‘goes over on his ankle’ develops an ankle sprain which may be of such severity as to avulse part of the bony attachment of the ligaments. ‘Footballer’s ankle’ is a condition where exostoses (bony growths) are found in the joint, and these can be dislodged into the joint causing a persist- ent painful ankle. Repeated trauma to the ankle joint is believed to be responsible for this condition.
Fractures of the foot may result from violence or from stress. A direct blow is not necessary to produce the fracture which can occur secondary to running continuously on hard surfaces. These stress fractures occur particularly in the metatarsal bones and are sometimes referred to as ‘march fractures’. The toes are also likely to be fractured by direct blows.
The toenail may be damaged and a sub-ungual haematoma may result producing acute pain.
The tendons of the foot bruise if subjected to a blow and this injury may simulate a fracture. The ligaments in the foot are also subject to strains. These injuries can result when two players attempt to kick a ball at the same time or from a player striking an opponent’s foot.
Blisters on the toes and soles of the feet are seen especially at the beginning of the season and in conditions where the grounds are hard. Friction between the boot and the skin causing pressure on the skin is responsible.
THE ENVIRONMENT AND SOCCER INJURIES As in most other field games, the environment and prevailing climatic conditions may play a role in the mechanism of soccer injuries. Muscles are believed to be more likely to suffer strain in conditions of extreme heat or cold. Tendon injuries and inflammatory-type injuries of the muscles of the lower leg show an increased incidence on hard grounds. Wet weather, producing muddy conditions underfoot may predispose to muscle strains. Pools of water on the pitch can be a hazard if the ball suddenly stops dead in the water; two players going for the ball, unable to correct their timing, can clash and a fractured leg or ankle results. Frost-affected grounds or excessively dry grounds, which are not rolled, can cause inversion type injuries of the ankle joint or more serious injury due to the ball running awkwardly, as the bumpy playing surface may be full of ruts and hard uneven ridges. Blisters on the toes and the soles of the feet are more liable to develop in these types of conditions. Severe grass burns or Astro-burns are inevitable consequences of soccer being played on hard or synthetic surfaces. Injuries resulting from players clashing with each other due to poor visibility are likely to occur where soccer is played under inadequate floodlights. In hot climates, insufficient protection of players with prophylactic electrolytes and water renders them liable to heat stroke or heat cramps. Because muscles and joints are often stiff after a night’s rest, there may be a greater likelihood of injury in the morning.
PREVENTION OF SOCCER INJURIES
Soccer players who are not physically fit are more likely to suffer from indirect muscle injuries. A flexibility routine to stretch muscle is essential in training, and strengthening of muscle is necessary to protect it when certain movements are being carried out in the game. For example, the neck muscles should be conditioned for heading the ball and the abdominal muscles for tackling. Weight training should be carefully supervised.
Many soccer players have ‘tight’ hamstring muscles and are predisposed to strains of these muscles as a result. Most clubs insist that warm-up exercises are done prior to training and matches, and provide special facilities for this purpose.
Correct technique is necessary not only to play the game well but also to cut down the incidence of injury. A player who does not tackle properly may injure either himself or his opponent. Basic tactical knowledge is also necessary. A player who passes a ball to another who at that point has no chance of avoiding an opponent’s tackle, may cause his team mate to be injured. Players who fail to communicate verbally with each other may collide when going for the same ball.
Equipment is another factor in the prevention of injury. The soccer boot with its low cut heel means that the soccer player is susceptible to ankle injuries. Nowadays the studs of the boot are checked by the referee prior to a game to ensure that sharp points do not act as a potential source of injury to another player. Shin guards should always be worn to protect the tibia and fibula from direct injury. The genitalia can be protected to some extent by the wearing of swimming trunks or jock-straps. Rings, chains or medals should not be worn while playing soccer as they may injure the wearer himself or another player. Tie-ups should not be too tight or they may bring on cramp. Boots should be correctly fitting, or painful blisters may result. The modern soccer ball is lightweight and without laces, and so the problems caused by the old leather ball which became unduly heavy in wet weather are no longer with us – nor are the problems caused by the lace of the old-style ball and the metal ‘eyes’.
The pitch should be in good condition and there should be no debris lying on it which could cause lacerations or abrasions.
A modification of the rules of the games and the dimensions of the pitch together with the use of a lighter ball is necessary where children are involved. Players in this category should be evenly matched as regards age, size and physique.
Good refereeing and intelligent interpretation of the Laws of the Game will reduce injury to a minimum and will eliminate dangerous play. All players should be in good health and should have received innoculation against tetanus.
The training programme should be carefully planned to provide a balance between all the components necessary for fitness. A footballer, when he is injured, should be handled by qualified personnel so as to prevent complications. Initial measures such as the appli- cation of ice to the injury, proper cleaning of wounds should be carried out to improve the player’s recovery prospects. A player returning from injury should be completely rehabilitated to prevent recurrence of the injury. He should not be asked to play before he has made a full recovery.
Smillie, I. S. (1970). Injuries of the knee joint. Churchill Livingstone, Edinburgh.
Williams, J. (1978). Injury in sport. Bayer, Haywards Heath.