Soccer all over the world

Soccer, or “Football” as it is called almost everywhere else in the world, culminates every 4 years into a month long event, the FIFA WORLD CUP, which is watched by over 33 billion people over the world. A number that is greater than any other single sport, including tennis, basketball and baseball. Soccer has a history that dates back to over 3000 years ago in Asia (Japan and China) where a small ball was kicked around by players on a field with the aim of kicking it into a net. The number of players on each team varied, and in some instances there were as many as 27 players on each team, leading to much chaosity and bodily injuries. Most games would end with many players needing hospitalization, having succumbed to bites, kicks, broken bones and many cuts and bruises. In the 14th century soccer (football) was deemed an illegal activity because of the violence and noise associated with it and anyone caught playing soccer (football) could face imprisonment. But thankfully, in the mid to late 1600’s the game was sanctioned in England and many teams were formed including England’s prestigious Harrow School that played a more organized soccer, which permitted catching of the ball. In 1815, Eton College established a set of rules that was later standardized and a version of this, known as the Cambridge Rules was later used by most of England's Universities and Colleges. The term soccer was reportedly coined in England when the name “AsSOCiation Football” was shortened and ER added by a student Charles Wreford Brown, who later played international soccer for England, when he was asked if he liked rugger (a term used for rugby), his reply was, ‘No SOCCER’. In the FIFA World Cup finals, thirty two teams across the globe, from 6 continents: 14 from Europe, 5 from Africa, 5 from Asia and South Pacific, 4 from South American and 4 from USA, Central America and the Caribbean) play to a 2nd round of 16, before the quarter final, then the semi-final and then the ultimate final match for the coveted golden world cup trophy.

With present day rules and regulations for soccer, the game is by far much less dangerous as compared to years ago when over 54 players could be found on the field during a game where kicking and biting was allowed. Nonetheless, soccer is fraught with injuries, most of which occur through contact with another player, the ground, the ball or rarely the goal post; or by excessive strain on body parts whether it’s the joints, muscles, ligaments or cartilages.

Injuries to the foot, ankle or lower leg are usually caused by direct contact from another player, twisting of the ankle or repetitive over use. High force contact injuries may cause fractures, in particular to the fibula. Severe soft tissue bruising with intramuscular bleeding may be seen with high velocity blows. In cases where the ankle “rolls over” or is twisted, in addition to ankle sprain with the disruption of the ligaments that stabilize the ankle, there may also be associated fractures of the bones on either sides of the ankle whether from compression or avulsion (pulling off of a piece of bone with the attached ligament or tendon). Repetitive overuse injuries may also lead to stress fractures of the tibia, fibula or in the foot.

Injuries of the Knee… are reported to be the most common site for serious soccer injuries. Mechanism of injuries varies from, violent twisting, overstretching to direct blows to the knee. Twisting of the knee, especially when the foot is planted on the ground, provides a great deal of torsion and searing forces in the knee, with or without traction. These movements are notorious for the popular injuries to the meniscus and cruciate ligaments and the cartilages in the knee. The history of a player twisting the knee with the resultant “locking “of the knee may give some indication that the meniscus with or without the cruciate ligament may be involved in the injury. The knee cap (patella) is also a common site of insult while playing soccer. It may occasionally be dislocated or fractured. Repetitive knee overuse may also result in pain around the patella, which may result in patellar tendonitis.

Injuries to the Thigh… are commonly caused by overstretching which gives strain (tears) of the hamstring, quadriceps or adductor muscles. Another cause of thigh injury is a kick to the thigh by another player or being hit by the ball after it was kicked with tremendous force. Muscular bruising can be so severe that the muscle fibers are compressed against the underlying bone and bone cells become deposited in the muscle resulting in boney spicules growing in the muscle ie myositis ossification which can be very painful.

Injuries to the Hands and Arms…are mainly due to the player falling on the outstretched hand. Shoulders may become dislocated or fractured, bones in the wrist may also become dislocated (lunate bone) or fractured (scaphoid bone) whenever a player falls awkwardly on his/her hand. However, the goalkeeper is the player most prone to upper extremity injury as he/she is the only player allowed to handle the ball likely leading to fingers or wrist fractures or dislocation.

Injuries to the torso...are often from being hit by the ball traveling at great speed after a powerful kick, esp. a ‘goal kick’, and more recently we’ve seen in the 2006 worldcup final, from a head butt to the sternum (chest). With high speed impact internal organs may be damaged e.g. kidneys, heart spleen or the breast in women or the genitalia in men. Players that stand in the line of defense, ‘the wall’, during a goal kick are commonly seem covering these areas with their arms as a means of protection.

Injuries to the Head and Neck… are most frequently from collision with another player or the goal post or blows from the ball. These injuries tend to occur when players are vying for the ball when it’s in the air. Head on head, head on elbow, head on foot, ball hitting the head (as opposed to head hitting the ball), can all give concussions, eye injuries, dental injuries, nose bleeds or nasal fractures, facial lacerations or bruising. The goalkeeper is especially vulnerable to collisions with the goal post as he/she is diving to retrieve a ball.

Injuries in Children…because of the smaller body mass of children, they are less prone to certain types of collision injuries. They do however, have very weak bones compared to the strength of their muscles and ligamentous tissues. This means if these weaker bones are subjected to the torsion and tension of the relatively stronger muscle, the site of injury is usually the site of tendon insertion into the bone resulting in an avulsion type fracture. With their growing immature bones they are prone to buckle (greenstick) fractures and epiphyseal plate fractures, which may lead to growth discrepancies. Compared to adults, children are to some extent less coordinated and may have a longer reaction time due to their developing nervous and musculoskeletal systems. They will also occasionally take more risks than adults and may be less likely to adequately assess a dangerous tackle. With their growing immature bones they are however prone to buckle (greenstick) fractures and epiphyseal plate fractures, which may lead to growth discrepancies. Osgood Schlatter’s disease is also seen below the knee where the quadriceps tendon inserts into the tibia and is placed under excess stress from repeated kicking of the ball.

Prevention is the key to avoiding injuries in soccer. A good referee, who ensures adherence to the rules and prevention of dangerous tackles, is essential. Players’ physical condition is another important factor; individuals who are unfit and have ‘tight’ unconditioned muscles are more prone to injuries. Well-trained athletes know the importance of warming up and warming down. Protective equipment is another method of minimizing and preventing injuries, e.g. shin pads for all players and gloves and quilted tops for the goalkeeper to cushion the impact with other players or with the ball. The condition of the field also plays a role in injuries; frozen or hard grounds increase the risk of injuries in players when they fall. Similarly, a wet, muddy and slippery field decreases the players’ ability to change direction and stop quickly as such he/she may be involved in more collision.

Paula U. A. Dawson MD

Dept Physical Medicine & Rehabilitation

Long Island Jewish Medical Center