Soccer, one of the most popular team sports in the world with over 200 million registered players worldwide, is a game of nonstop action. Most injuries in soccer occur in the lower body, mostly to the knees and ankles. However, repeated or prolonged use (overuse) injuries are common problems, especially toward the end of a long and grueling season. These injuries are the result of constant overloading and wearing down of a tendon (tissue connecting muscle to bone), muscle, bone or joint, resulting in the inability of that structure to perform its normal biomechanical duties.

Types of Injury
The rate of injury in soccer has been reported to be between 15 and 20 injuries per 1000 hours of play. The rate is slightly higher for female players than male participants. Injuries range from a severe bruise to more traumatic type injuries (broken bones). Overuse injuries are responsible for almost 30% of the injuries in soccer and range from mild tendonitis (swelling of a tendon) all the way to a stress fracture.

Symptoms
Inflammation (swelling) is the most common sign of an overuse injury. The signs of inflammation are redness, warmth and swelling, pain with movement, pain to deep touch, and a grinding feeling over the muscle as it is moved. One or all of these signs may be present. In the early stages, players may feel an aching pain after practice. As the injury gets worse, the pain will occur during practice or games with increasing pains as an attempt is made to maintain a high level of performance.

Youth and adolescent players are most at risk for overuse injuries during times of rapid growth. Strong muscle pull at the tendon-bone junction and at the attachment to the growth plate can cause inflammation. One common adolescent overuse injury is Osgood-Schlatter's disease (apophysitis). It is a painful bump where the patella (knee cap) tendon attaches to the tibia, or shin bone, (Fig. 1). This can become inflamed by repetitive running or jumping. Tight hamstrings seem to go hand in hand with this injury. An injury such as this should not be ignored because it could lead to a complete separation of the tendon from the bone.

Sever's disease is another common area of pain in the young soccer player (age 7 and older). It is a growth plate inflammation of the calcaneus (heel bone), which may mimic Achilles tendinitis (Fig. 2 left) Other areas of growth plate inflammation can occur at the pelvic rim, the thigh muscle attachment to the hip, the hamstrings, and the groin muscles attachment to the pelvis.

The worst case in the spectrum of overuse injuries is the stress fracture. This results from an inability of the bone to keep up with the increasing demand placed upon it. The result is a fracture (break) of the bone (Fig. 3 below).

Adult soccer players also suffer from overuse injuries. Common places for injuries in adults are the Achilles tendon, plantar fascia (tissue that runs from the heel bone to the toes), inside of the lower leg shin (shin splints), and at the knee. Improper footwear and playing on hard surfaces can lead to these injuries. If left untreated these injuries can lead to tendon rupture.

Prevention
Players should be aware of their physical condition. Even seemingly minor injuries should be treated appropriately. Injuries tend to increase as players fatigue, so adequate rest is essential. Players should also warm-up and stretch prior to any practice or game, and warm-down and stretch afterwards.

Treatment is P.R.I.C.E.-less
Prevention is the most important part of the equation. Rest involves giving the injured tissue adequate time to repair itself. Ice is used to decrease inflammation and should be applied before and after practice or games over the injured body part.

Compression involves applying an elastic wrap over the injured part to help reduce swelling. Elevation helps to decrease swelling by using gravity to assist in the process. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and aspirin, are also used to reduce swelling. During periods of acute pain, athletes should consider a stop in play and allow time for the injury to heal.

Conclusion
Proper conditioning, appropriate training techniques, quality footwear, proper warm-up and stretching, and paying attention to the bodies early warning signs can prevent overuse injuries. Early treatment with rest, ice, compression, and elevation can shorten time away from playing. If the signs and symptoms persist, players should get medical attention to prevent further injury.

Gary A. Levengood, M.D.
Alpharetta, Georgia