How You Can Help Prevent Soccer Injuries Before they Happen

Recent statistics indicate that there are three million youth soccer players in the United States.¹ As soccer’s popularity continues to surge and trends continue toward early sport specialization with year-round soccer participation, the potential for increased injury incidence grows. Lower extremity injuries commonly occur during soccer, and injuries to the four major muscle groups of the lower extremity (hip adductors, quadriceps, hamstrings, and calf) account for 90% of all muscle injuries in soccer.²

Groin injuries account for 4% to 19% of all soccer injuries in males and 2% to 14% in females, and hamstring injuries account for 13% to 17% of all acute injuries in soccer. Unfortunately, many of these injuries also have a high rate of recurrence, up to 30% for hamstring and 29% for hip adductor injuries.³

Fortunately, recent research evidence demonstrates a significant decrease in lower extremity injury incidence with the use of specific injury prevention exercises. A warmup program implementing many of these exercises was also shown to improve lower extremity biomechanics and risk factors demonstrated to correlate to lower extremity injury risk.4

Many of the following exercises may easily be integrated into a warmup or strength and conditioning program to limit injury risk in lower extremity muscle groups commonly used during soccer activities.

Multiple studies examining lower extremity injury mechanisms during soccer activities have identified common recurring at-risk susceptible positions or activities. A common injury mechanism identified in multiple studies involves defensive pressing or tackling where the player is forced to quickly and unexpectedly react to the movements of an opposing offensive player.5-7 This forces defensive players to asymmetrically load or stress one leg suddenly during deceleration and/or acceleration maneuvers, requiring significant strength and control in single leg positions.

Mimicking and simulating these forces under controlled conditions with plyometric and specific training exercises to improve motor control and ability to control these forces, may reduce injury risk in these at-risk positions. Many of these plyometric training exercises can be done on-field with minimal equipment requirements. 

It is imperative that soccer athletes demonstrate adequate lower extremity flexibility, strength, and motor control to prevent injury. A lack of hip extension range of motion, hip flexor and quadriceps weakness, and inadequate lumbopelvic control may contribute to increased injury risk related to compensations and overload muscles, particularly rectus femoris during the kicking motion.The following stretches may be useful in soccer athletes to allow adequate hip extension and abduction ROM.

Optimal hamstring and calf flexibility are also useful to minimize the risk of lower extremity injury and movement compensations.

Exercises for the anterior trunk and hip musculature may be useful to ensure adequate lumbopelvic motor control to allow optimal force production during soccer activities, specifically kicking and sprinting, without overloading the rectus femoris and hamstring muscles. The rectus femoris and hamstring muscles attach at the pelvis and may be influenced by trunk position and postures. The related exercise progressions shown below may limit injury risk to the hip flexors, rectus femoris and quadriceps muscles, and the hamstrings through improved pelvic position and control related to muscle length and force production. 

The Reverse Nordic exercises for soccer athletes can be used for strengthening the quadriceps muscle group and demonstrates beneficial changes to muscle structure. 5 The eccentric stress with the Reverse Nordic exercise may be useful to replicate soccer demands and induce beneficial changes.5

Additionally, the Copenhagen exercise to eccentrically train the hip adductor and groin muscles demonstrated improved hip adductor strength and decreased injury incidence in multiple research studies.This exercise is shown in the accompanying video and requires minimal equipment to implement. 

Similarly, the Nordic hamstring exercise is used to eccentrically train the hamstrings and can also be performed easily on field or in a training facility with minimal equipment. Multiple research studies show a decrease of up to 51% in long term hamstring injury incidence in soccer when using the Nordic hamstring exercise versus typical training or warm-up programs.7,8

The combined use of the Copenhagen and Nordic Hamstring exercises improved dynamic balance and lower extremity stability in a recent research study , which provides further evidence to include these exercises in a soccer injury prevention program.9

Gluteal muscle strength and motor control, specifically at glute medius are essential to single leg balance and limiting injury risk in soccer athletes.10,11 The side plank with hip abduction and lateral step-down exercises shown below had high levels of glute medius activation for strengthening benefits and should be included in a soccer-specific injury prevention program. 11

Dynamic balance and lower extremity stability may also be strongly influenced by muscle groups at the ankle and distal leg. The functional heel drop exercise was shown to induce beneficial changes at the gastrocnemius and calf musculature to improve strength and capacity to limit injury risk.12,13

Soccer-specific agility and footwork drills incorporating change of direction and rotational movements may also be useful with injury prevention programs to replicate soccer demands in single leg balance positions to optimize stability and motor control. 

The FIFA 11+ program was designed as a comprehensive soccer-specific warmup and injury prevention program to simulate many of the specific sport demands.

Multiple studies reveal a significantly decreased injury incidence in soccer athletes implementing the FIFA 11+ program versus control groups using a general or traditional warmup program.14-17 Adherence to the FIFA 11+ warmup program was also shown to have beneficial effects on balance, motor control, and agility which are related to soccer injury risk.

 


REFERENCES

1. US Youth Soccer

2. Ekstrand J, Hägglund M, Waldén M. Epidemiology of muscle injuries in professional football (soccer). Am J Sports Med. 2011 Jun;39(6):1226-32. doi: 10.1177/0363546510395879. Epub 2011 Feb 18. PMID: 21335353.

3. Hägglund M, Waldén M, Ekstrand J. Risk factors for lower extremity muscle injury in professional soccer: the UEFA Injury Study. Am J Sports Med. 2013 Feb;41(2):327-35. doi: 10.1177/0363546512470634. Epub 2012 Dec 21. PMID: 23263293.

4. Thompson JA, Tran AA, Gatewood CT, Shultz R, Silder A, Delp SL, Dragoo JL. Biomechanical Effects of an Injury Prevention Program in Preadolescent Female Soccer Athletes. Am J Sports Med. 2017 Feb;45(2):294-301. doi: 10.1177/0363546516669326. Epub 2016 Oct 29. PMID: 27793803; PMCID: PMC5507196.

5. Lucarno S, Zago M, Buckthorpe M, Grassi A, Tosarelli F, Smith R, Della Villa F. Systematic Video Analysis of Anterior Cruciate Ligament Injuries in Professional Female Soccer Players. Am J Sports Med. 2021 Jun;49(7):1794-1802. doi: 10.1177/03635465211008169. Epub 2021 May 14. PMID: 33989090.

6. Della Villa F, Buckthorpe M, Grassi A, Nabiuzzi A, Tosarelli F, Zaffagnini S, Della Villa S. Systematic video analysis of ACL injuries in professional male football (soccer): injury mechanisms, situational patterns and biomechanics study on 134 consecutive cases. Br J Sports Med. 2020 Dec;54(23):1423-1432. doi: 10.1136/bjsports-2019-101247. Epub 2020 Jun 19. PMID: 32561515.

7. Waldén M, Krosshaug T, Bjørneboe J, Andersen TE, Faul O, Hägglund M. Three distinct mechanisms predominate in non-contact anterior cruciate ligament injuries in male professional football players: a systematic video analysis of 39 cases. Br J Sports Med. 2015 Nov;49(22):1452-60. doi: 10.1136/bjsports-2014-094573. Epub 2015 Apr 23. PMID: 25907183; PMCID: PMC4680158.

8. Mendiguchia J, Alentorn-Geli E, Idoate F, Myer GD. Rectus femoris muscle injuries in football: a clinically relevant review of mechanisms of injury, risk factors and preventive strategies. Br J Sports Med. 2013 Apr;47(6):359-66. doi: 10.1136/bjsports-2012-091250. Epub 2012 Aug 3. PMID: 22864009.

9. Alonso-Fernandez D, Fernandez-Rodriguez R, Abalo-Núñez R. Changes in rectus femoris architecture induced by the reverse nordic hamstring exercises. J Sports Med Phys Fitness. 2019 Apr;59(4):640-647. doi: 10.23736/S0022-4707.18.08873-4. Epub 2018 Oct 1. PMID: 30293403.

10. Schaber M, Guiser Z, Brauer L, Jackson R, Banyasz J, Miletti R, Hassen-Miller A. The Neuromuscular Effects of the Copenhagen Adductor Exercise: A Systematic Review. Int J Sports Phys Ther. 2021 Oct 1;16(5):1210-1221. doi: 10.26603/001c.27975. PMID: 34631242; PMCID: PMC8486394.

11. Al Attar WSA, Soomro N, Sinclair PJ, Pappas E, Sanders RH. Effect of Injury Prevention Programs that Include the Nordic Hamstring Exercise on Hamstring Injury Rates in Soccer Players: A Systematic Review and Meta-Analysis. Sports Med. 2017 May;47(5):907-916. doi: 10.1007/s40279-016-0638-2. PMID: 27752982.

12. van Dyk N, Behan FP, Whiteley R. Including the Nordic hamstring exercise in injury prevention programmes halves the rate of hamstring injuries: a systematic review and meta-analysis of 8459 athletes. Br J Sports Med. 2019 Nov;53(21):1362-1370. doi: 10.1136/bjsports-2018-100045. Epub 2019 Feb 26. PMID: 30808663.

13. Saleh A Al Attar W, Faude O, Husain MA, Soomro N, Sanders RH. Combining the Copenhagen Adduction Exercise and Nordic Hamstring Exercise Improves Dynamic Balance Among Male Athletes: A Randomized Controlled Trial. Sports Health. 2021 Nov-Dec;13(6):580-587. doi: 10.1177/1941738121993479. Epub 2021 Feb 15. PMID: 33588644; PMCID: PMC8558994.

14. Burnham JM, Yonz MC, Robertson KE, McKinley R, Wilson BR, Johnson DL, Ireland ML, Noehren B. Relationship of Hip and Trunk Muscle Function with Single Leg Step-Down Performance: Implications for Return to Play Screening and Rehabilitation. Phys Ther Sport. 2016 Nov;22:66-73. doi: 10.1016/j.ptsp.2016.05.007. Epub 2016 May 20. PMID: 27592407.

15. Boren K, Conrey C, Le Coguic J, Paprocki L, Voight M, Robinson TK. Electromyographic analysis of gluteus medius and gluteus maximus during rehabilitation exercises. Int J Sports Phys Ther. 2011 Sep;6(3):206-23. PMID: 22034614; PMCID: PMC3201064.

16. Alonso-Fernandez D, Taboada-Iglesias Y, García-Remeseiro T, Gutiérrez-Sánchez Á. Effects of the Functional Heel Drop Exercise on the Muscle Architecture of the Gastrocnemius. J Sport Rehabil. 2020 Nov 1;29(8):1053-1059. doi: 10.1123/jsr.2019-0150. Epub 2019 Dec 6. PMID: 31810057.

17. Bayer ML, Hoegberget-Kalisz M, Svensson RB, Hjortshoej MH, Olesen JL, Nybing JD, Boesen M, Magnusson SP, Kjaer M. Chronic Sequelae After Muscle Strain Injuries: Influence of Heavy Resistance Training on Functional and Structural Characteristics in a Randomized Controlled Trial. Am J Sports Med. 2021 Aug;49(10):2783-2794. doi: 10.1177/03635465211026623. Epub 2021 Jul 15. PMID: 34264782.

18. Sadigursky D, Braid JA, De Lira DNL, Machado BAB, Carneiro RJF, Colavolpe PO. The FIFA 11+ injury prevention program for soccer players: a systematic review. BMC Sports Sci Med Rehabil. 2017 Nov 28;9:18. doi: 10.1186/s13102-017-0083-z. PMID: 29209504; PMCID: PMC5704377.

19. Thorborg K, Krommes KK, Esteve E, Clausen MB, Bartels EM, Rathleff MS. Effect of specific exercise-based football injury prevention programmes on the overall injury rate in football: a systematic review and meta-analysis of the FIFA 11 and 11+ programmes. Br J Sports Med. 2017 Apr;51(7):562-571. doi: 10.1136/bjsports-2016-097066. Epub 2017 Jan 13. PMID: 28087568.

20. Gomes Neto M, Conceição CS, de Lima Brasileiro AJA, de Sousa CS, Carvalho VO, de Jesus FLA. Effects of the FIFA 11 training program on injury prevention and performance

in football players: a systematic review and meta-analysis. Clin Rehabil. 2017 May;31(5):651-659. doi: 10.1177/0269215516675906. Epub 2016 Nov 3. PMID: 27811329.

21. Steffen K, Emery CA, Romiti M, Kang J, Bizzini M, Dvorak J, Finch CF, Meeuwisse WH. High adherence to a neuromuscular injury prevention programme (FIFA 11+) improves functional balance and reduces injury risk in Canadian youth female football players: a cluster randomised trial. Br J Sports Med. 2013 Aug;47(12):794-802. doi: 10.1136/bjsports-2012-091886. Epub 2013 Apr 4. PMID: 23559666.

Dan Bien, Physical Therapist

Dan has worked at University Orthopedics since 2006 and serves as the Coordinator of Clinical Education for the physical therapy department. He received a Master of Science degree in Physical Therapy from Thomas Jefferson University in Philadelphia and a Bachelor of Science degree in biology from Villanova University. Dan is currently recognized as an Orthopedic Certified Specialist by the American Board of Physical Therapy Specialties, a Certified Strength and Conditioning Specialist through the National Strength and Conditioning Association, and a Credentialed Clinical Instructor by the American Physical Therapy Association. Dan completed a sports medicine physical therapy residency at the University of Cincinnati where he worked extensively with collegiate athletes. He has presented nationally on multiple topics related to rehabilitation of the knee and shoulder. Additionally, Dan has published peer-reviewed journal articles on ACL rehabilitation and injury prevention, and performs related clinical research activities.