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Heading injuries out of soccer:
A review of the literature
Monash University Accident Research Centre – Report No. 125
Full
report in pdf version
Authors: A.C. McGrath & J. Ozanne-Smith
November 1997
Abstract:Soccer is the most popular sport in the world, and one of the most
popular in Australia. Soccer is characterised as vigorous, high
intensity, intermittent, ball and contact sport. The characteristics of
soccer along with the required functional activities obviously places
great demands on the technical and physical skills of individual
players. A direct blow from a soccer ball or a stray kick may result in
fractures, bruising, or even death. Soccer players can also suffer from
a range of overuse injuries associated with running, jumping, pivoting,
heading and kicking of the ball. The overall aim of this report is to
critically review both the formal literature and informal sources that
describe injury prevention measures, or countermeasures, for soccer. The
range of countermeasures for preventing soccer injuries is presented in
this report, together with an assessment of the extent to which they
have been formally demonstrated to be effective. Such countermeasures
include pre-season conditioning, protective equipment including shin
guards, warm-up programs, attention to environmental conditions,
adequate footwear, modified rules, education and coaching, first aid and
rehabilitation. Recommendations include the need to conduct more
biomechanical and epidemiological research into the mechanisms of
injury; further development and testing of protective equipment;
improving education for both players and coaches, particularly at the
wider community level; adopting modified rules for children; extending
pre-participation screening to the general soccer community; providing
prompt first aid; and improved injury data collections, particularly for
the less formal level of play.Executive SummarySoccer is characterised as vigorous, high intensity, intermittent,
ball and contact sport. Functional activities include acceleration,
deceleration, jumping, cutting, pivoting, turning, heading and kicking
of the ball . It is obvious that the game of soccer puts many demands on
the technical and physical skills of the individual player . Soccer is
one of the most popular sports with over 270,000 registered Australian
players and approximately 200 million players in 186 countries
registered with the International Federation of Football Association .
Further there is estimated to be a equal number of unlicensed soccer
players .With an increase in popularity and expectation of players, along with
the characteristics of soccer, significant numbers of injuries are
conceivable. Although a significant amount has been published on the
epidemiology and biomechanics of soccer injuries, there are few formal,
controlled evaluations of the effectiveness of injury prevention
countermeasures.This report aims to critically review both formal literature and
informal sources that describe injury prevention measures
(countermeasures). It provides an evaluation of the extent to which
these countermeasures have been demonstrated to be effective. Unlike
other literature describing soccer injuries, this report does not
specifically focus on the epidemiology of soccer injuries, nor their
aetiology. Instead, it presents a detailed examination of the range of
countermeasures promoted to prevent soccer injuries. A brief overview of
the epidemiology of soccer injuries, particularly from an Australian
perspective, is given to set the scene for the subsequent discussion of
countermeasures.Recommendations for further research, development and implementation
are based on the review presented here and discussions with experts
acknowledged in this report. Many of the recommended countermeasures
have not yet been proven to be effective and further controlled
evaluation studies are needed. A summary of the countermeasures reviewed
and recommendations for further research, development and implementation
are given below.LOWER LEG INJURIES AND TECHNIQUEThe nature of the game of soccer, in which players make sharp turns
off a planted foot, and intense contact with the ball and other players,
along with the essential underlying components of running and kicking,
indicate the vulnerability of the lower extremities. The epidemiological
soccer literature clearly indicates that the majority of soccer injuries
occur to the lower extremities. Lower extremity injuries account for
between 58% to 93% of all injuries for adults and 39.1% to 89% for
children. The dominant injuries occur to the knees, ankles and shins.
Countermeasures include correct footwear and shin guards.Recommendations
- Studies are required on the causes and prevention of lower leg
injuries. Research questions still to be answered included:
- Which features of footwear are protective against soccer
injuries?
- Where should the balance lie between foot protection and
stabilising effects of footwear and flexibility of shoes etc.?
- What is the interaction between footwear and specific playing
surfaces?
- Do cushioning effects of footwear mask longer term damaging
effects?
- Research studies need to take into account measures of exposure
such as hours played, hours of training, position on the field etc.
- Evidence on the effects of interventions between footwear and
surfaces should be reviewed with reference to other sports.
- Where the effectiveness of countermeasures have been proven and
regulated eg. shin guards, enforcement at all levels of the game
during practice and competition should occur.
- Shin guards and footwear should be further and continually
developed.
- Equipment such as shin guards and footwear should be fitted with
professional advice.
- The use of wobble board training should be encouraged.
HEAD INJURIESWhile the vast majority of soccer injuries occur to the lower
extremities, injuries to the head and neck may also occur. From the
international literature, the proportion of total injuries to the head,
spine and trunk areas ranges from 4-22% in adults and 9-26% in youths.
Head injuries are sustained from heading the ball, ball strikes to the
head and head to head contact, most often when two players attempt to
head the ball simultaneously. Common head injuries include lacerations
and concussion. Unlike injuries to the lower extremities, injuries to
the head and neck have greater potential to be catastrophic. Recommendations
- Use only plastic coated balls
- Once water resistance qualities are lost, replace the ball.
- Use the appropriate sized ball for the age and gender group
playing.
- Teach the player to head correctly and to maintain eye contact
with the ball before and after contact is made (Dods, undated).
- Ensure the head and neck are kept rigid at impact and, once this
basic technique has been acquired, only then progress to the
standing jump and finally to the running jump (Dods, undated).
- The development of strong neck musculature, to keep the neck
rigid at impact (Dods, undated).
- Strengthen the hip flexor and abdominal muscles for the
ballistic action in the standing header.
- Children should be specifically trained and monitored in terms
of correct heading technique
- Investigations should be made into the advantages and
disadvantages of a lightweight helmet for soccer.
- Epidemiological research into the incidence of head injuries and
associated factors should be undertaken
- Current evidence is not conclusive, thus further controlled
studies of heading need to be conducted.
- The recommendations made by NHMRC should be endorsed.
FACIAL INJURIESMost sports can give rise to dental, mouth and face damage, though
contact sports such as soccer, have been shown to have a relatively
higher incidence. There is an absence of FIFA rules for protection from
orofacial injury and no mention of such devices in texts for coaches and
athletes.Recommendations
- Investigate the advantages and disadvantages of developing a
light weight soccer helmet.
- Epidemiological research into the incidence and circumstances of
eye, dental and face injuries should be undertaken based on
participation rates.
- Barriers to the use of mouthguards should be determined.
- Mouthguards should be used by all players.
GOAL POSTSOver a 16 year period (1979-1994), the Consumer Product Safety
Commission, a United States federal government agency, reported at least
21 deaths and an estimated 120 injuries involving falling soccer goal
posts had been treated in US hospital emergency rooms. These statistics
do not encompass the numerous injuries that occur and do not receive
emergency treatment.Recommendations
- Ensure both portable and permanent goals are securely anchored
to the ground.
- Ensure portable goals are made of a lightweight material.
- Dismantle, remove, tie up or secure to a permanent structure
portable goals after use.
- Cover goals with protective padding.
- Conduct further research into goal post design.
- Conduct epidemiological studies looking at the mechanism and
types of injuries associated with goal posts.
RULES OF THE GAMEPushing, holding, barging, tripping, striking or intentional kicking
are not allowed in soccer and free-kicks are awarded when rules are
broken. If a player commits a serious foul, abuses an official or
continues to break the rules, then they can be warned with a yellow
card, or sent from the field with the presentation of a red card.Recommendations
- Players need to be educated that foul play is not an acceptable
part of the game.
- The deterrent effect of the send off rule with limited
substitution, should be examined in comparison with the benefits of
encouraging injured players to leave the field with unlimited
substitution.
- Rules need to be enforced.
CROWD CONTROLA major concern to the reputation and popularity of soccer is the
worldwide risk of injury and even death through crowd violence. Although
Australia has been less prone to this than other countries, signs of
tensions in supporting crowds have begun to emerge in recent years. Recommendations
- Ensure that the FIFA regulations are fully enforced
PHYSICAL PREPARATIONA soccer player needs to meet at least minimum physical,
physiological and psychological requirements to cope with the demands of
competition and reduce the risk of injury. Individual player factors are
often related to soccer injuries and can be prevented through
corrections in training and conditioning. Warm-up and stretching is also
recommended to increase playing ability, however, its role in injury
prevention is controversial.Recommendations
- More research into the role of warm-up, training and
conditioning as an injury prevention measure for soccer is needed.
- Controlled research studies should be undertaken into the
benefits of different types of warming-up, cooling-down and
stretching practices.
- Information about warm-up, cool-down and stretching techniques
should be developed and widely promoted to improve specific
knowledge of techniques and effectiveness.
- Simple fitness testing should be conducted prior to soccer
competition to ensure adequate fitness levels for competition.
- Appropriate education and monitoring of players should be
conducted regarding nutritional and hydration demands of soccer,
particularly as intensity increases with a training programme, and
emphasising complex carbohydrate intake
- Recreational soccer players should not train excessively. If
fitness is the overall goal, soccer drills could be interspersed
with other activities.
- Soccer players should consider some form of cross-training (eg.
bicycling) to improve their fitness levels and remain injury free.
- Soccer skills and fitness should be built-up gradually.
- Soccer players with potential biomechanical abnormalities (eg.
leg length discrepancies) should have these assessed by a
professional who can recommend corrective actions.
- More research is needed to determine the threshold and optimal
levels of the various training factors under which soccer players
are likely to remain injury free.
- A campaign aimed at increasing soccer players’ awareness of the
injury consequences of training errors should be developed and
promoted.
PREVENTING OVERUSE INJURIESSoccer players, like any athletes today, are expected to train harder
and longer, and to commence at an earlier age, if they are to succeed at
the elite level. It is, therefore, not surprising that there is an
increasing number of overuse injuries. An overuse injury results from an
accumulation of stresses to the involved tissue - bone, ligaments or
tendons. Alternatively, an overuse injury could result from a previous
injury for which the body compensates, by increasing the stress on
another part of the body, eventually leading to tissue breakdown and
overt injury at the vulnerable site.Recommendations
- More research into the aetiology of overuse injuries needs to be
undertaken.
- Soccer players should be educated about the risk and severity of
overuse injuries.
- Soccer players with potential biomechanical error (eg. leg
length discrepancies) should have these assessed by a professional
who can recommend corrective actions.
- Coaches and trainers should be educated in the importance of
gradual increases in training, particularly pre-season or in the
early part of the season.
ENVIRONMENTAL CONDITIONTraditionally soccer is played on a rectangular field, predominantly
a grass surface, and less commonly a surface of sand, gravel or
artificial turf. During a game a player covers a large percentage of
this area and suffers significant impact forces of two to three times
body weight. For this reason the surface and the environmental surrounds
are important factors to consider when reviewing the nature and
incidence of soccer injuries. Recommendations
- Risk management plans to control environmental hazards should be
developed, implemented and monitored for facilities.
- More research into the role of environmental conditions such as
playing surface and weather conditions should be undertaken in a
controlled manner.
- Soccer should not be played under extremes of weather
conditions.
- Adequate player hydration should be ensured.
- Soccer players should use a broad spectrum sunscreen in high
ultra-violet conditions
- A wet globe bulb temperature system should be available at all
soccer matches which are played under hot and humid conditions to
assess heat load.
- Risk management plans should incorporate specific regulations
regarding the environment.
- Further research needs to be conducted on the interaction
between footwear and specific playing surfaces.
- Evidence on the effects of interventions between footwear and
surfaces should be reviewed with reference to other sports.
MODIFIED RULES AND CHILDRENSignificant differences exist between child and adult athletes.
Therefore injury prevention strategies for children should be considered
separately to those for adults, despite the fact that their injuries may
be attributed to many of the factors associated with adult soccer
players.Recommendations
- The modified rules version of soccer (Rooball) should be widely
implemented
- Children should be encouraged to play with smaller sized balls
as in Rooball at all times
- Children and adolescents should be taught correct techniques and
procedures.
- The use of shin guards should be enforced.
EDUCATION AND COACHINGEducation, as a component of injury prevention should cover a wide
range of aspects such as facilities, training and treatment. Guidelines
have been produced by the Australian Sports Commission and the
Australian Soccer Federation to aid in school education programs,
particularly on Rooball and progression to traditional soccer.Recommendations
- All coaches should be accredited and undergo regular
re-accreditation.
- Coach education schemes should be updated regularly to ensure
they provide current information.
- Instruction clinics for the wider community should be developed
and made widely available.
- Education resources for informal soccer need to be developed and
disseminated.
- Schools should seek advice from the Aussie Sports Program in
terms of modified rules, as well as the state organisation for
guidance on program development.
FIRST AID AND REHABILITATIONInjuries need to be properly managed to restrict the possibility of
further damage. Overall, the treatment goals are pain relief, promotion
of healing, decreased inflammation, and a return to functional and
sports activities as soon as possible. This procedure may involve, first
aid, taping or bracing, referral and general rehabilitation.Recommendations
- Controlled research is needed to determine the effectiveness of
taping and bracing of ankle and knee joints in the primary
presentation of injury
- Taping or bracing should be considered by professionals in the
prevention of re-injury of ankle joints
- Return to play after injury should only occur after full
recovery
- Qualified first aid personnel should be available at all
sporting events.
- Conduct research into the biomechanics of acceleration,
deceleration, jumping, cutting, pivoting, turning, heading and
kicking of the ball.
- Ensure that all players have prompt and adequate first aid
treatment.
- Further players should undergo controlled rehabilitation before
returning to play after an injury.
INDOOR SOCCER/FUTSALIndoor soccer, is played by over 100 countries with 12 million
players world wide. Futsal is the only official form of indoor soccer
approved under the auspices of the FIFA. While the strategy is the same
in both indoor and outdoor soccer, the confined indoor area demands
quick reflexes, fast thinking, and pin-point passing and leads to an
increase in injuries. Indoor soccer injuries are generally similar to
those of the outdoor game.Recommendations
- Well designed studies are required to determine the relative
risk of injury between indoor and outdoor soccer.
- Epidemiological studies in terms of the mechanism of injury and
the relation to the games surrounds needs to be conducted.
- Risk management plans should be prepared, implemented and
monitored based on the apparent risk of futsal.
GENERAL SUMMARY AND CONCLUSIONSThis report has discussed hospital emergency department data,
epidemiological data presented in the literature and the full range of
injury prevention activities for preventing soccer injuries. The
proportion of emergency department presentations reported for both child
and adult injury in Victoria was generally within the ranges found in
the literature in terms of body region and nature of injury. In addition
to specific recommendations, the following more general recommendations
have been made:
- Improved data collection about the occurrence of soccer injuries
and their associated factors needs to be developed and maintained.
- Data about injuries and their associated factors in recreational
soccer needs to be collected.
- Data collections should conform to guidelines for sports injury
surveillance being developed and promoted nationally.
- Information about preventing soccer injuries should be
disseminated widely through soccer broadcasts, soccer equipment
points of sale, soccer and general magazines.
- Guidelines for minimum safety requirements for soccer events
(including the need for mobile phones, telephone contacts, first aid
kits, etc) should be developed and widely disseminated.
- Future research studies to determine risk factors and to
evaluate the effectiveness of countermeasures need to be controlled.
- Risk management plans for sporting bodies, clubs and
associations should be developed, implemented, enforced and
regularly reviewed.
Risk management plans for facilities should be developed and
implemented.This project was funded by Sport and Recreation Victoria
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