Sports Medicine: Just the Facts

CHAPTER 89 • SOCCER 529

occurs coupled with maximal eccentric quadriceps con-

traction to supply the force in the noncontact rupture of

the ACL.

• Contact ACL injuries in male soccer players follow a
  pattern of collision with a valgus stress to the knee
  resulting in associated injuries to the menisci, the col-
  lateral ligaments, and the articular cartilage.


• In the cases of chondral injuries, extreme stress is
  placed on the articular cartilage through repetitive
  abrasive wear of high velocity pivoting and decelera-
  tion or the acute disruption of the deep cartilage ultra-
  structure by large shear forces. Chondral lesions are
  more often seen on the femoral condyle. Acute X-ray
  imaging for a swollen knee should include tunnel
  views to rule out an osteochondral fracture and if pres-
  ent, should be staged by knee MRI and co-managed
  with an orthopedic surgeon.

LOWER LEG INJURY

•A soccer player’s lower leg is vulnerable to abrasions,
contusions, and fractures. Shin guards have become
the only mandatory protective devices in soccer, but
serve primarily to protect the leg from minor soft
tissue injuries. (Boden et al) reported in his series of
soccer tibial and fibular fractures that 90% occurred in
athletes wearing shin guards.

• The more typical scenarios involving lower leg
  injuries of any severity occur with aggressive slide
  tackles from behind with injury to the offensive
  player’s fixed leg or when opposing players contest a
  loose ball in scoring position where a haphazard
  swinging kick or a lunging foot results in high veloc-
  ity contact (Boden, 1998).
  •With combined tibia and fibula fractures the soccer
  player is sidelined on average of 40 weeks. Isolated
  fibula and tibia fractures return to competitive play on
  average of 18 and 35 weeks, respectively. Both com-
  bined tib-fib fractures and isolated tibial fractures
  have a high incidence of recovery complications
  (Boden, 1998).
  •Overuse injuries to the lower extremity span the broad
  differential for exertional lower leg pain. These
  include but are not limited to compartment syndrome,
  medial tibial stress syndrome (MTSS), and stress frac-
  tures.


• Anterior tibial compartment syndrome can be insidi-
  ous with the effort dependent running pain that
  reduces performance over several months to years. Or
  in another scenario, an acute compartment syndrome
  may occur when a player sustains a high velocity kick
  to the protected or unprotected anterior or lateral
  lower leg. In both cases, the player may describe

lower leg pain with tingling and/or weakness extend-

ing on to the dorsum of the foot. Diagnostic stryker

compartment testing and comanagement with an

orthopedic surgeon should follow.

• Normal connective tissue and bone adaptation occurs
  in cyclic progression. Injury patterns for MTSS and
  stress fractures are multifactorial and are exercise
  dose dependent where extremes of frequency, inten-
  sity, and duration are common contributors.


• Stress fractures and MTSS are diagnostic challenges
  best differentiated by triple phase bone scan and
  treated with varying degrees of activity modification.

GROIN INJURY

• The mechanism of groin injury in the soccer athlete is
  associated with the ball manipulation skills where the
  leg gets overstretched at the groin while the hip is
  abducted and externally rotated, sometimes against an
  opposing force, such as the ground or the opponent.
  This process of overstretching compromises the ado-
  lescent’s apophysial pelvic ring or pubic attachments
  or in the case of the senior player the muscular—
  tendonous attachments.


• Groin pain can follow a pattern of overuse that starts
  with adductor muscle tendonopathy. These cases
  should be distinguished from osteitis pubis and sports
  hernias, which can present with a similar pain pattern.
  •Hip flexor strain to the iliopsoas is common in
  soccer and is characterized by deep groin pain with
  an occasional snapping hip sensation or pain exten-
  sion onto the anterior thigh. Treatment consists of
  relative rest with stretching of the hip flexors and
  rotators. An iliopsoas strengthening program should
  precede the return to competitive play (Morelli and
  Smith, 2001).


• Groin disruption was named Gilmore’s Groin in 1980
  following the successful treatment of three profes-
  sional soccer players who had been sidelined with pain
  for 3 months. Clinical symptoms include the insidious
  unilateral pain in the adductor region that progresses
  with activity and follows a course of post activity
  aggravation getting out of bed or the car. Examination
  findings are minimal and variable but may include ten-
  derness and dilation of the internal inguinal ring on
  scrotal hernia palpation. The features of this condition
  include torn external oblique aponeurosis, torn con-
  joined tendon—conjoined tendon tear from the pubic
  tubercle, dehiscence between conjoined tendon and
  inguinal ligament, and no palpable hernia. Diagnosis
  should include stork radiographs to evaluate pelvic sta-
  bility. Cases that fail the rehabilitative process should
  go to surgery for repair (Gilmore, 1998).