Football injury prevention

Arguably football is the most popular sport in the world today with an estimated 260 million people playing the game from the elite player to the not so elite player. Television views of the game have rocketed over the years attracting 109 million viewers for the UEFA Champions League Final and approximately 500 million viewers for the FIFA World Cup Final (1-3). 

Patrick Nzuzi - Professional footballer

However, due to the popularity of the game, Injuries in football is very prevalent with an estimated rate of 34% of footballers potentially suffering an injury with the lower limb being the most affected extremity (4). When we think that 260 million people on average are playing the game plus the potential injury rate of 34% that’s potentially 85 million injuries! If we can reduce this injury rate globally then this would reduce medical expenses the footballer’s pain and frustration through lost time sitting on the bench whilst recovering. In this Health News article we will briefly discuss preventative measures that you can take to limit your risk of potentially gaining a football injury.

Advantages and Disadvantages

The disadvantages being previous studies have tried but failed to demonstrate that by stretching certain areas of the body may reduce injuries prior to a game (6). However the advantages are that other studies have demonstrated that by performing a sufficient warm-up will reduce your general risk of potentially gaining a football injury prior to a game (7). Using evidence based practices is all very well and good but reducing the risks of potential injuries is also down to the individual coach, trainer and therapist expertise and experience (8).  

 

Common football injuries (although not exhaustive) that are seen by health professionals are; ankle sprains, torn / pulled hamstrings, ruptured anterior cruciate ligament (ACL) and groin injuries. By recognising the most common injuries (ankle sprains, torn / pulled hamstrings, ruptured anterior cruciate ligament, groin injuries) we can start to look at the ways to help reduce the risks of these common type of football injuries.    

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Ankle sprains

Ankle sprains can occur during the game due to the many manoeuvres involved such as pivoting, twisting, turning, alongside jumping and landing on the playing surface. These manoeuvres can place your ankle in a vulnerable position by means of rolling over and by sustaining a potential sprained ankle of variable degrees of severity from a slightly pulled ligament to a complete ruptured ligament.

Preventative steps

To help limit the risk of an ankle sprain you can perform proprioceptive training. Proprioceptive training involves the body’s ability to sustain sufficient alignment and balance which in itself is a multifactorial skill. Proprioceptive training focuses on not just balance but the body’s systems senses which can be improved through this type of training. Research has demonstrated that this type of training can lower injury risks of sustaining an ankle sprain (9).

This can be performed by simply standing on one leg or by use of a multi balance board such as a wobble board and by increasing the intensity of the exercise by performing different body manoeuvres such as a squat or by simply closing the eyes.

Ankle strapping

Studies have demonstrated that by strapping the ankle by use of tapes, elastic strapping wraps and ridged braces may limit the risk of sustaining an ankle sprain particularly in patients with a previous history of an ankle sprain (10). Arguably ankle strapping and taping is also thought to have a neurological or psychological effect particularly when the mechanical effects are no longer working. 

Torn / Pulled Hamstring

Hamstring muscle injuries are most likely to occur in sports such as sprinting and kicking such as football and athletics (11-14). Hamstring strains account for 25% of all strains reported and are considered one of the most common injuries in sport (15-17). The majority of hamstring injuries occur in the biceps femoris and at the musculotendinous junction, however they may also occur in the semimembranosus whilst stretching (18). Clark et al. (19) refers to injury when the hamstrings have to work eccentrically to decelerate the tibia to control knee extension especially during powerful eccentric muscle actions. This can occur during two phases of the running cycle, late forward swing and toe off as the hamstrings decelerates hip flexion and knee extension resulting in larger eccentric loads (11,12).

Preventative steps

Research has demonstrated by improving your eccentric hamstring strength you will reduce your risk of sustaining a hamstring injury (20,21). I find these exercises particularly useful for those individuals and footballers that have a previous history of a hamstring tear as I rarely see them back in the clinic! Here are two exercises on how to reduce your risk (see figures 1 and 2)  

Figure 1

Figure 2

A ruptured Anterior Cruciate Ligament (ACL)

This is one of the most common injuries that we see in football as the ACL plays a crucial role in maintaining knee stability. This type of injury can be a little more challenging to treat due to a number of factors - the player’s anatomical make-up, gender and playing surface.

 

The ligament runs through and towards the front centre of the knee to help hold the femur and tibia together by preventing one from sliding forward on the other during leg flexion and extension. Consequently if injured and left unattended the ligament may not heal properly resulting in instability of the knee joint thereby leading to injury to other ligaments, thus leading to mechanical limitations of the knee joint (22,23). 

The mechanism of a ACL injury is a valgus/external rotation trauma with a slightly bent knee that may involve a non-contact injury such as a sharp twisting action where the foot is planted whilst the individual is trying to change direction or during activities that involves deceleration internal/valgus stresses including activities that involve the jump stop phase or if the knee is involved in hyperextension motion in conjunction with internal rotation which may result in a torn ACL (24-26). A distinct pop is often heard by the individual with the sensation of the knee giving way (24-28).

In Sports and football we generally class sport related ACL tears as;

  • Indirect contact (often appears uncommon with knee valgus collapse)

  • Direct contact (often associated with knee valgus collapse)

  • Classic non-contact (often appears uncommon with knee valgus collapse)

 

ACL tears in football are generally non-contact in nature with the most common injury setting during defensive (pressing) playing actions.

Preventative steps

For ACL injury prevention it is imperative that biomechanical function is maintained or restored to the joints and lower extremities by strengthening weak muscles and stretching common taut muscles such as the quadriceps, hamstrings, gastrocnemius and iliotibial band. Consequently muscles such as the vastus medialis obliques may be weaker than the opposed vastus lateralis muscle which may result in an irregular muscle contraction. Emphasis on duration of strengthening muscle contractions may be necessary such as closed chain exercises (wall squats) performed only to 30°of flexion are recommended (30). Authors such as Carraffa et al., (31) found in a prospective controlled study that pre-season proprioception training in semi-professional footballers on a balanced/wobble board reduced ACL injuries significantly by 10 injuries per 300 players compared to those that didn’t 70 injuries per 300 players.  

 

Other research has demonstrated that if a player has more control during an inward (valgus) direction then they will likely reduce their risk of sustaining an ACL injury (29). A simple way to do this is by improving your gluteal (buttock), trunk / abdomen and core muscle strength. A great way to improve this and often performed by many football clubs as part of their core strength training programmes are theraband walks, the plank (figure 3) and side-plank (figure 4) although there are many variations. 

Figure 3

Figure 4

Groin injuries

Groin injuries are very prevalent in sports such as football due to kicking and high speed directional changes involved and account for 10-23% of all injuries (32-34). Often the hip adductors are most commonly injured due the potential eccentric forces stressing the muscle-tendinous complex via manoeuvres of side-to-side cutting and kicking (33-37)

 

Studies have demonstrated that hip and groin pain throughout the season can be up to 70% resulting in absence, lost time and more worryingly this may suggest players are continuing to play with pain (38-40)

 

Preventative steps

Previous research studies have demonstrated that groin injuries or hip adduction weakness strength has been a contributing risk factor for a new groin injury (41-45). To date although the efficacy of football groin injury programmes are unknown, active groin injury prevention programmes and specific exercise programmes suggest that such an approach is potentially worthwhile in football to help reduce injury deficits (32).

 

We can help reduce the risks by performing active strength and coordination exercises by focusing on the adductor and abdominal muscles and muscles in and around the pelvis which has been an effective treatment for long-standing groin pain problems (32,45-48). 

 

Warm-ups

To limit long term risks and fear of injury or re-injury it is recommended that athletes use a variety of techniques to prevent injury such as warm ups and stretching exercises including suitable conditioning programmes relevant to the athletes sport (21,49-51)

 

It is important to understand that when performing warm-ups that all exercise is movement but not all movement is necessarily an exercise therefore you should utilise a variety of movements and skills. This will improve your body to adapt by being able to have more variable resources to your specific sport.

This link to FIFA’S 11+ warm-up programme, if done correctly should take approximately 15-20 minutes. FIFA 11+ is considered to be a fundamental tool to help reduce injury risks in football as well as having substantial health benefits. Furthermore football teams that have implemented the FIFA’s 11+ have seen a reduction of injuries ranging from 30-70% (52,53).  

Playing surfaces   

To date from reviewing the available research there is no difference in total injury rates for acute injuries on those that play on artificial turf (AT) vs natural grass (NG) in elite male football. Although there is a difference in injury pattern, less injuries but more contusions on AT playing surfaces.

 

Research suggests that AT clubs are likely to have higher injury rates compared to natural grass clubs particularly in overuse injuries. Footballers that play on AT surfaces have higher Injury rates which include a 60% increase in hip / groin overuse injuries and 4-fold increase in lower leg overuse injuries (54). 

 

The risks of sustaining a football injury

Research suggests that newcomers to professional male football have fewer total injury rates compared to established players but likely to have higher rates of stress fractures. Injury rates increase with age, goalkeepers have fewer injury rates compared to outfield players although to date no differences have been reported in outfield players injury rates (55).    

  

Summary

Football is a very popular sport enjoyed and loved by many but it also has its high risks of injury. To reduce the risks of sustaining a football injury performing pre-rehabilitation exercises by including a good strength and conditioning programme and ensuring that you perform a good warm-up session such as the FIFA’s 11+ then this should likely reduce your risk of injury.

 

As always thank you for taking the time to read this Health News article’ and enjoy your football.

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References

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