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Injury Incidence, Body Site, and Severity in Soccer Players Aged 6–18 Years: Implications for Injury Prevention

Rumpf, Michael Clemens MS1; Cronin, John PhD2

Strength and Conditioning Journal: February 2012 - Volume 34 - Issue 1 - p 20-31
doi: 10.1519/SSC.0b013e31821a9833
Article
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INJURY INCIDENCE DATA FOR YOUTH PARTICIPANTS IN SOCCER HAVE BEEN COLLATED AND SUMMARIZED. SUCH INFORMATION SHOULD FORM A BASIS FOR INJURY PREVENTION PRACTICES. PLAYER CONTACT ACCOUNTS FOR MOST INJURIES (40–66%), WHEREAS THE LOWER EXTREMITIES ARE CONSIDERED THE MOST VULNERABLE INJURY SITE IN THE BODY (70%). STRAINS (24%), SPRAINS (31%), AND CONTUSIONS (20%) ACCOUNT FOR 75% OF ALL INJURIES REPORTED THROUGHOUT THE INCLUDED LITERATURE. THESE SOFT TISSUE INJURIES RESULT IN MINOR (1–3 DAYS, 18%), MILD (3–7 DAYS, 36%), AND MODERATE (>1 WEEK, 30%) RECOVERY DURATIONS. SPECIFIC CONSIDERATIONS FOR INJURY PREVENTION PROGRAMS ARE PRESENTED.

1Sports Performance Research Institute New Zealand, Auckland University of Technology, Auckland, New Zealand; and 2School of Exercise, Biomedical and Health Sciences, Edith Cowan University, Western Australia

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Michael Clemens Rumpf is a PhD candidate at the Auckland University of Technology.

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John Cronin is the director of the Sport Performance Research Institute New Zealand and professor of Strength and Conditioning, Exercise Science Stream.

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INTRODUCTION

By most reports, soccer is among the most played and/or the most popular sport in many countries. Many athletes in different age groups are participating in organized and unorganized soccer settings, and as such, injuries will occur across all levels of age and play. With injury, practice and competition time are lost. This is especially important in the developmental years of a player (6–18 years). To minimize lost playing time, injury surveillance data need to be collated and translated into injury prevention programs. By understanding the common types of injuries, age relevance, and injury mechanisms, the strength and conditioning coach may formulate a plan to prevent injury.

Several different investigations have presented injury data on soccer players aged 6–18 years, with the focus on one or a combination of the following points: gender comparison (18), age comparisons (14,18,26), and maturity groups; frequency and type of injuries, injury site, and severity (26); soccer experience (18) and skill level (14); position-specific injuries (18); injury history (18); games versus practice injury risks (26); injury occurrence at the time of the game (26); mechanisms of injury during game and practice (26); and seasonal injury occurrence (12). This article summarizes the major findings from these studies and provides information to guide training practices to prevent injuries in youth soccer.

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CONSIDERATIONS

Several considerations need to be addressed to understand how surveillance reports were created and how data were evaluated and presented.

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DEFINITION OF INJURY AND SEVERITY

The amount of registered injuries may vary depending on the definition of an injury. The common injury definition was related to injured players' absence in training or games for more than 48 hours, not including the day of the injury (19,20,26). The severity of injury was based on the duration of absence from training or competition and classed into 4 categories: minor (2–3 days), mild (4–7 days), moderate (1–4 weeks), and major (>4 weeks) (19,20,26).

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REPORT OF INJURIES AND TYPE OF ASSESSMENT

There are multiple ways to assess and report injuries. Specific persons or institutions were used to diagnose and report injuries, that is, a physician (19,20,26), a certified trainer (3), or staff from a medical clinic (9). Another option was the utilization of retrospective questionnaires (13,14).

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INJURY OCCURRENCE IN DIFFERENT AGE GROUPS

Tables 1–4 present injury incidence per 1,000 hours and the affected body site of soccer players, including age associations. The inclusion of studies for data reporting consisted of a 3- to 4-year age range, gender-specific play, and competitive play undertaken by male participants in outdoor soccer. The analysis of literature did not include any reference to maturation level, injury history, playing position for the participants, or monthly injury data specifics. It should be noted that data were not presented for the 6- to 8-year-old soccer players because of the paucity of quality literature in this area.

Table 1

Table 1

Table 2

Table 2

Table 2

Table 2

Table 3

Table 3

Table 4

Table 4

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MAJOR FINDINGS

CAUSES OF INJURIES

Causes of injury can be related to intrinsic (person-related) or extrinsic (environment-related) factors (6). Examples of each designation are given below:

Intrinsic (person-related) factors are as follows:

  • Joint instability, muscle strength, tightness, and asymmetry
  • Body mechanics
  • Psychological (30)
  • Injury history (18).

Extrinsic (environment-related) factors are as follows:

  • Level of play and position on the field (5,24,25,30)
  • Amount and standard of training and competition (2)
  • Warm-up and stretching (1,2)
  • Pitch (indoor/outdoor) (10)
  • Quality of pitch (33)
  • Rules of play
  • Equipment.

Contact injuries accounted for 40–66% of injuries (5,11,13,15,16), whereas reinjury and poor pitch conditions seemed to be responsible for many injuries as well (2,7).

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INJURY INCIDENCE IN TRAINING VERSUS GAMES

In comparison with training situations, games involve greater speed and generally more stress on the players' body. As a result, there are more injuries, and more severe injuries are expected to happen in games compared with training sessions.

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INJURY INCIDENCE IN DIFFERENT LEVELS OF PLAY

Questions arise whether higher soccer skills/standards and level of play influence injury incidence. High-skilled players versus low-skilled players were identified via coach ratings (30) or by their team placement in a league system. Therefore, teams of high-skilled players were placed in higher leagues than those involving low-skilled players (5,24,25). Because of different skill levels and involvement in the game, players' injury incidence varied. Low-level players experienced a greater amount of injuries in general (30) and a greater amount of severe injuries (24) compared with high-skilled players. The risk probability for severe injuries was twice as high for low-skilled players compared with high-skilled players (5). However, Chomiak et al. (5) also stated that there were no general differences between low- and high-skilled groups in frequency of injury. In general, high-skilled players were cited as those with lower injury risks (24). Possible explanations were a greater exposure to training (24) and therefore a higher training to game ratio, whereas low-skilled players attended more competitions, where injuries occurred more often (25).

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INJURY INCIDENCE IN DIFFERENT LEVELS OF EXPERIENCE

Less experienced soccer players were reported to have a higher incidence of injury compared with experienced players (30). It is proposed that experienced players were able to avoid injury because of their familiarity with injury-causing situations.

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INJURY INCIDENCE IN CONNECTION WITH THE AMOUNT AND STANDARD OF TRAINING

A higher amount of training sessions and a longer preseason period were related to fewer injuries during the competitive season (2). Additionally, the quality of the training was another factor influencing injury occurrences in soccer. Proper warm-up and stretching programs were related to absence of muscle strain injuries (1). Evidence for the effectiveness of proper warm-up and flexibility procedures was observed in adult soccer (8). Shooting on goal before warm-up was the main reason for quadriceps strains. The absence of special flexibility programming for hamstrings increased strain injury risks (8).

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INJURY OCCURRENCE ACCORDING TO PLAYING POSITION

Defenders and midfielders were injured more often than strikers and goalkeepers. Generally, the incidence of injury increased with age for all positions, except for goalkeepers. Goalkeepers younger than 14, 15, and 16 years experienced similar levels of injury compared with field players.

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DIFFERENCES IN INJURY OCCURRENCE, BODY SITE, AND SEVERITY ASSOCIATED WITH DIFFERENT MATURITY STATUSES

Maturity status was not related to the risk of injury in youth soccer players (19). Early and normal maturers experienced a nonsignificant higher injury incidence compared with late maturers. Normal maturation of subjects referred to a skeletal maturity within 1 year of chronological age; early maturation referred to a skeletal maturity older than 1 year of chronological age, and late maturation referred to a skeletal age more than 1 year younger than chronological age. However, the severity of injury was greater in late maturers compared with early maturers. The one and only significant difference between players in different maturational groups was related to knee injury as the most injured site in normal and late maturers compared with the thigh in early maturers. Early maturers experienced greater incidence of groin injuries, strains, and sprains, whereas normal maturers experienced more back problems compared with other maturational groups.

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DIFFERENCES IN INJURY OCCURRENCE OVER THE CALENDAR YEAR

Injuries vary throughout the season. Training injuries peaked in/after preseason in January, and competitive injuries peaked after a midseason break (26). However, Le Gall et al. (19) determined that September had the highest rate of injuries, but Chomiak et al. (5) did not find any differences in injury occurrence over different months of the year.

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DIFFERENCES IN INJURY OCCURRENCE WITH RESPECT TO INJURY HISTORY

Youth players with a previous injury or youth athletes with multiple injuries were at greater risk of injury incidence. Players with a single previous injury had a 2-fold greater risk of injury. Two or more previous injuries altered the risk of injury to 3 times the risk in players without previous injuries (18). Besides individual injury histories, insufficient rehabilitation was a critical factor in reinjuries.

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DIFFERENCES IN INJURY OCCURRENCE IN MALES VERSUS FEMALES

Girls show a 2-fold greater injury risk in comparison with boys (28,33). Females Women were responsible for 44% of all reported injuries (33) and represented 27% of the studied population. A higher injury rate in female soccer players compared with the male counterparts of the same age was explained by the lack of experience and inferior technical skills (4). However, a more recent study reported only a non-significant higher risk for girls compared to boys (32).

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DIFFERENCES IN INJURY OCCURRENCE IN INDOOR VERSUS OUTDOOR SOCCER

Youth soccer players (<16 years of age) had a 2-fold greater chance of sustaining a training injury. Indoor soccer has a 4.5-fold greater injury risk than outdoor soccer (13). Not only the injury occurrence but also the severity of the injuries were different in indoor versus outdoor soccer. Severity differed as 6.5% of outdoor injuries and 24.3% of indoor injuries required medical assistance (13). The lower extremities were the most common site for an injury in both environments.

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BODY SITE, TYPE OF INJURY, AND SEVERITY

Table 5 and Figures 1–3 summarize data pertaining to the affected body site, type of injury, and severity of injury in youth soccer athletes aged 7–19 years. In assimilating this information, no attention was paid to age bands, maturation level, injury history, players' positions, game injury versus training injury, or time frame in the calendar year.

Table 5

Table 5

Table 5

Table 5

Table 5

Table 5

Figure 1

Figure 1

Figure 2

Figure 2

Figure 3

Figure 3

The lower extremities are the most affected body site for injuries (70%) (Figure 1). However, 56% of all injuries are healed within 1 week (Figure 2). The most common injuries were ankle sprains (31%), strains (23%), and contusions (20%) (Figure 3).

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SUMMARY AND PRACTICAL APPLICATIONS

In terms of injury prevention, it would seem that enforcing rules of fair play in soccer is important because more than 60% of all injuries are from contact situations. Complete rehabilitation of a player's injury is critical in prevention of reinjury. Strength and conditioning coaches, athletic trainers, and/or physiotherapists need to ensure that the players complete progressive functional exercise programs and a comprehensive battery of tests before returning to play.

Players' physical preparations in the form of training and appropriate injury prevention programs might affect the incidence of injury. High training/game time and longer preseasons have been shown to lower injury occurrence (8) and proper warm-up and stretching procedures (1). Therefore, warm-up and injury prevention can be combined into a single protocol. The FIFA 11+ as a soccer-specific warm-up and injury prevention program has already been established and shown to reduce injury in young female soccer players (31) and improved physical abilities of young male soccer players (17). Further soccer-specific preparation programs should also take different forms of muscle contractions, including speed and joint position related to game actions. In addition to injury prevention programs, specific screening programs would help identify players who are more likely to get injured, that is, players with injury history, muscle tightness, asymmetries, and joint instability.

The injury prevention program for youth soccer needs to account for the following research outcomes: (a) injury incidence increased with age and especially after the age of 14 regardless of maturity and experience, (b) the lower extremities, mainly the ankle and knee joints and accompanied muscles and ligaments of the thigh and calf, were the most injured body site (∼80%), (c) severe injuries were more likely to be experienced by low-skilled players, (d) indoor soccer had a greater risk of injury compared with outdoor soccer, (e) poor pitch conditions were a significant external factor affecting injury occurrence, and (f) higher incidences of injury occurred in female players.

Finally, only few studies investigated the injury occurrence and its relation to maturity status. As stated previously, injury occurrence was not significantly different in various maturation levels (19). Injuries increase steadily with age but definitely after the age of 14, which coincides with peak height velocity (PHV) or pubescence in boys. Therefore, an optimal time to introduce sport-specific preparation and injury prevention protocols would occur before the onset of PHV. Further research should take maturation, injury occurrence, injury history, reinjuries, and especially etiology of injury into consideration. To gain better insight into the prevention of soccer injuries, more information pertaining to subject parameters (position played, accumulated training hours, and physical ability) and characteristics (maturation, flexibility, and asymmetries) is needed for youth soccer players.

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      Keywords:

      youth soccer; injury; prevention; incidence; body site; severity

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