Heads up for soccer injuries! What you need to know

Soccer is the world's most popular sport. Although it does not draw large crowds of spectators in the United States, soccer has attracted a steadily increasing number of youthful participants during the past two decades. According to the Soccer Industry Council of America, nearly 8 million children younger than 12 years and almost 6 million 12- to 17-year-olds participated on club teams in 1997.¹ Many factors-such as the game's simple rules and inexpensive equipment-account for the boom in soccer but, for parents, soccer's chief attribute is its reputation as a "safe" sport.

Nonetheless, the number of children who are injured while participating in soccer has increased along with the sport's growing popularity. Pediatricians who care for active children should therefore be prepared to evaluate and manage soccer-related injuries and know when to refer. In addition, you should be able to provide parents with guidance about the risks of participation and be knowledgeable about how best to avoid soccer injuries. This requires familiarity with developmental criteria for participation, the preparticipation physical, and appropriate protective gear and preseason training.

Epidemiology of injury Several studies conducted in Europe and the US have examined the incidence of injury in youth soccer.^2-7 Although methodologic differences (including how "injury" is defined) make those studies difficult to compare, several patterns emerge from the data. Most soccer injuries are "minor" and typically involve the lower extremities. Significantly, the injury rate increases with participants' age, and girls tend to be injured more often than boys. Major injuries (fractures and ligament sprains) are most often to the knee and ankle.

Acute injury The following case studies illustrate a few of the more serious injuries that occur in soccer-as well as in other sports that demand frequent dynamic and explosive movement. These cases offer common clinical presentations and mechanisms of injury.

Knee injury Denise, a 16-year-old girl, comes to your office with a painful, swollen right knee. When she was dribbling the ball during yesterday's soccer practice, she tried to quickly "cut" to her left. As Denise planted her right foot, her knee buckled and she heard a loud "pop." She was unable to continue practice because her leg felt weak. Upon awakening this morning, Denise discovered that the knee had swelled overnight.

Eliciting the precise mechanism of injury can be quite helpful in forming the differential diagnosis of an acute knee injury. In this instance, a twisting of the knee combined with an audible "pop" suggests that the anterior cruciate ligament (ACL) has been injured. Other traumatic knee injuries to consider based on the history are a meniscal tear, osteochondral fracture, or dislocation of the patella. A meniscal tear or osteochondral fracture typically would not elicit a "pop" but, more likely, a "grinding" or "crunching" sensation. Patellar dislocation is usually quite apparent to the athlete and typically reduces spontaneously. In this case, the presence of a large, tense, swollen knee (hemarthrosis) is indicative of an intra-articular injury (ligament rupture, meniscal tear, intra-articular fracture).

Examination of the injured knee begins with observation for gait abnormality, gross deformity, and effusion. Next, assess the passive, active, and resistive ranges of motion. If a large effusion is present, knee flexion will be limited because the distended joint capsule cannot expand further. Full extension is often limited in an ACL injury because of associated tibial plateau and femoral condylar bone bruising. Medial collateral ligament (MCL) injury also may prevent full extension in the acute postinjury period.