Jan Gillquist

Soccer injuries and their mechanisms: a prospective study

In order to study the incidence and mechanisms of injury in soccer and to recommend prophylactic measures, 180 players in a senior male soccer division were followed prospectively for 1 yr. Attendance records for games and practice sessions were kept, and all injuries were examined and treated by the same orthopaedic surgeon. One hundred twenty-four players incurred 256 injuries, mostly sprains and strains of the lower extremities. Of these, 62% were considered minor with ankle sprains being the most common (17%), while 11% were considered major with knee ligament sprains being the most frequent (32%). Overuse injuries were most frequent in the preseason training period. Traumatic leg injuries involved players with inadequate or no shin guards. Of the traumatic knee injuries, 11 of 18 (61%) occurred during a collision; non-contact knee injuries were frequently seen in those players with a history of knee injury and existing instability. Study of injury sequence disclosed that a minor injury was often followed within two months by a major one. In addition, with severe injuries incurred during fouls, the individual causing the penalty was injured. This prospective study suggested that those with knee instability and those allowed to resume play with poorly rehabilitated or clinically unhealed injuries are more apt to sustain further injury. Some injuries can be avoided by using better equipment and by observance of the rules.

Prevention of ankle sprains

Two different methods for the prevention of ankle joint injuries in soccer were tested. Coordination training on an ankle disk improves functional stabilty and postural control, whereas an orthosis provides mechanical sup port. Both techniques reduce the frequency of ankle sprains in soccer players with previous ankle problems. The orthosis is an alternative to taping, and can be used during the rehabilitation period after injury or when playing on uneven ground. Coordination training on an ankle disk ought to be included in the rehabilitation of ankle injuries to prevent functional instability. It may also be done prophylactically by players with previous ankle problems in order to break the vicious circle of recurrent sprains and feeling of giving way.

Stabilometry in functional instability of the ankle and its value in predicting injury

Stabilometry is an objective method used for studying postural equilibrium quantitatively. Stabilometric recordings were made in 127 soccer players to demonstrate functional instability of the ankle joint. The presence of previous ankle joint injuries, i.e., sprains or fractures, was documented. Reference values for stabilometry were obtained from a group of 30 normally-active non-soccer players without a history of injury to the ankle joint. A pathological stabilometric value was defined as one exceeding the mean value of the reference group by 2 SD. In players with a history of previous ankle joint injury no increased postural sway was found. On the other hand, players showing abnormal stabilometric values ran a significantly (P less than 0.001) higher risk of sustaining an ankle injury during the following season compared to players with normal values. Players with a history of previous ankle joint injury did not run a higher risk compared to players without previous injury. The findings indicate that an ankle joint injury did not result in a persistent functional instability; however, such instability did increase the risk of ankle joint injury.

Anterior Cruciate Ligament Reconstruction and the Long Term Incidence of Gonarthrosis

Knee ligament injuries are common in sport. A rupture of the anterior cruciate ligament (ACL) is the most serious of these injuries because it may cause long term disability. In this literature review, the frequency of post-traumatic gonarthrosis is examined. There are few long term prospective studies but a number of retrospective studies with follow-up times between 5 and 20 years have been published. These studies show that radiographic gonarthrosis is significantly increased after all knee injuries compared with the uninjured joint of the same patient. Isolated meniscus rupture and subsequent repair, or partial or total ruptures of the ACL without major concomitant injuries, seem to increase the risk 10-fold (15 to 20% incidence of gonarthrosis) compared with an age-matched, uninjured population (1 to 2%). Meniscectomy in a joint with intact ligaments further doubles the risk of gonarthrosis (30 to 40%), and 50 to 70% of patients with complete ACL rupture and associated injuries have radiographic changes after 15 to 20 years. Thus, an ACL rupture combined with meniscus rupture or other knee ligament injuries results in gonarthrosis in most patients.Ten to 20 years after ACL injury, gonarthrosis often presents as a slight joint space reduction or, occasionally, joint space obliteration (Ahlbäck grades I to II), but is usually not associated with major clinical symptoms. According to the few longitudinal studies, the progress of gonarthrosis is slow, and in some cases the condition seems to remain stable. Time is an important determinant for the degree of gonarthrosis and problems demanding treatment may be encountered only at >30 years after the initial accident.

A performance test to monitor rehabilitation and evaluate anterior cruciate ligament injuries

A performance test simulating components of sports was devised to evaluate dysfunction after ACL injury. The test included a one-leg hop, running in a figure of eight (straight running and turn running measured sep arately), running up and down a spiral staircase, and running up and down a slope. Twenty-six men with ACL injury, most of them soccer players, and 66 uninjured male soccer players were studied. Patients with ACL injury performed signifi cantly less well than the uninjured players. Test items of special interest were turn running in the figure of eight, stair running, and slope running, all of which place high demand on the knee. It is concluded that a performance test of this design is useful for monitoring rehabilitation and for evaluating the patients condition. Before sports can be resumed at the original level, normal strength and normal per formance should be regained.

Surgical or non-surgical treatment of acute rupture of the anterior cruciate ligament. A randomized study with long-term follow-up.

One hundred and eleven consecutive patients who had acute injuries to the knee that included rupture of the anterior cruciate ligament, as shown by physical examination with the patient under anesthesia and by diagnostic arthroscopy, were randomized to three treatment groups: simple repair of all injured structures, repair of all injured structures and augmentation of the anterior cruciate ligament with a strip of the iliotibial band, and repair of all injured structures except the anterior cruciate ligament. In all other respects, the knees were treated in an identical fashion. Of the 111 patients, 107 were re-examined forty-five months or more after operation. At the most recent follow-up, the knees that had been treated by repair and augmentation of the anterior cruciate ligament were significantly more stable and had had significantly fewer subsequent meniscal tears. Sufficient instability to necessitate late reconstruction was also less frequent in the patients who had had an augmented repair. These patients had better function of the knee and a higher level of activity than the patients in the other two groups. Sixty-four per cent of these patients who had a rupture of the anterior cruciate also had a meniscal tear, and primary care was indicated for more than 50 per cent of the tears. Therefore, we believe that early arthroscopic examination is essential for patients who have an acute rupture of the anterior cruciate ligament.

Prevention of soccer injuries Supervision by doctor and physiotherapist

To study the efficacy of an injury prevention program in a randomized trial, 12 teams (180 players) in a male senior soccer division were followed up for 6 months. The 12 teams were allocated at random to two groups of six teams, one being given a prophylactic program and the other serving as control. The program was based on previous studies of injury mechanisms. It comprised (1) correction of training, (2) provision of optimum equipment; (3) prophylactic ankle taping; (4) controlled rehabilitation; (5) exclusion of players with grave knee instability; (6) information about the impor tance of disciplined play and the increased risk of injury at training camps; and (7) correction and supervision by doctor(s) and physiotherapist(s). The injuries in the test teams were 75% fewer than in the controls. The most common types of soccer injuries, sprains and strains to ankles and knees, were all significantly reduced. It is concluded that the pro posed prophylactic program, including close supervi sion and correction by doctors and physiotherapists, significantly reduces soccer injuries.

Incidence of soccer injuries and their relation to training and team success

One hundred-eighty players in a male soccer senior division of 12 teams were observed prospectively for 1 year to study the risk of soccer injuries in relation to exposure and to establish the connection between training, injuries, and team success. Totally, more than 100 hours of practice were analyzed. All injuries were examined by the same orthopaedic surgeon. On the average, each team played 36 games and had 95 practice sessions with 66% attendance of selected players. A direct correlation was noted be tween team success and the amount of training. Teams with more than average training showed a diminishing number of injuries. A high practice-to- game ratio seems to be advantageous. One injury every third game and every ninth practice session was documented. For the individual player the incidence of injury was 7.6/1000 practice hours and 16.9/1000 game hours. The incidence of injury was higher at training camps. Correlation was noted between the design of the train ing and the incidence of injuries. The duration of warming up seemed adequate, but its content did not appear to be satisfactory from a clinical point of view. Redesign of the warm-up with more emphasis on flexibility and the addition of a cool-down is suggested to reduce injuries.

The long-term course after treatment of acute anterior cruciate ligament ruptures A 9 to 16 year followup

Acute total ACL (N = 60) and concomitant medial collateral ligament (N = 46) ruptures were repaired in 60 patients (mean age, 28 years) without augmentation. Menisci were removed in 23 knees. Fifty-three (88%) of the patients were reexamined 9 to 16 years later with special emphasis on manual and instrumented stability testing (Stryker, Genucom), knee function score (Lysholm), and activity level (Tegner). Standing roentgenograms (30° of knee flexion) were taken in 69% of the patients. At followup, an ACL reconstruction had been performed in seven patients (12%) due to symptomatic instability. Sixty-four percent of the knees had a positive Lachman sign and 40% a positive pivot shift. Sagittal laxity difference was +3 mm or more in 57%. Knee function score was a mean of 86 ± 12 points. The mean activity level had changed from rec reational team sports (Level 7) to recreational individual sports (Level 5). Only patients with good knee stability were able to perform demanding sports and could continue at their desired activity level. Osteoarthritis of slight to moderate degree (Fairbank I/II) was found in 58% of the patients younger than 35 years of age at the time of trauma and in 87% of the older patients. Knees with intact menisci had less osteoarthritis than knees with removed menisci (P < 0.05).

The frequency of muscle tightness and injuries in soccer players

One hundred-eighty players in a male, senior soccer division were examined for past injuries, persisting symptoms from past injuries, and muscular tightness in the lower extremities. Soccer players were in general less flexible than a group of nonplayers of the same age (n = 86). No correlation was found between past injuries and ex isting muscle tightness. Sprains of the lower extremity, especially of knees and ankles, predominated among the injuries. Persistent instability symptoms were common se quels to knee and ankle injuries. It is proposed that intensive care of acute injuries will improve the late results.