Given the popularity of soccer and the fact that most soccer injuries involve the lower extremity, this author offers pertinent treatment tips on ankle sprains and strains, pearls on proper shoe fit and keys to orthotic modifications.
A large-scale 2006 Federation Internationale de Football Association (FIFA) survey shows that soccer is the world’s number one sport. There are 265 million male and female players, and 5 million referees and officials. A grand total of 270 million people — or 4 percent of the world’s population — are actively involved in the game of soccer.1
Of the 18 million Americans who play soccer, 78 percent are under the age of 18. In the 1990s, soccer was recognized as the fastest growing college and high school sport in the United States.2 The popularity of soccer has grown, especially among women, since the U.S. women’s soccer team won the World Cup in 1991 and 1999. In the United States, 35 percent of soccer players are women, one of the highest percentages of female participation in soccer in the world. Female participation in high school soccer has risen by more than 177 percent since 1990.3
Previous studies have shown that soccer has a high injury rate and injury percentage. More injuries occur in soccer than field hockey, volleyball, handball, basketball, rugby, cricket, badminton, fencing, cycling, judo, boxing and swimming. Most soccer injuries occur to the lower extremities, especially the ankle.4
Player to player contact is reportedly a contributing factor in 44 to 74 percent of soccer injuries. Most ankle sprains occur during running, cutting and tackling activities. Sixty-seven percent of foot and ankle injuries occur from direct contact. Significantly more injuries involve a force from the lateral or medial direction in comparison to an anterior or posterior direction. Researchers have noted that the weightbearing status of the injured limb is a significant risk factor.5
High school soccer participation in the United States increased fivefold over the last 30 years. With increased participation comes increased injury incidence. Overall, the most frequent diagnoses were incomplete ligament sprains (26.8 percent), incomplete muscle strains (17.9 percent), contusions (13.8 percent) and concussions (10.8 percent). The most commonly injured body sites were the ankle (23.4 percent), knee (18.7 percent), head/face (13.7 percent) and thigh/upper leg (13.1 percent).6 Sprains, contusions and strains of the lower extremities were the most common injuries in men’s collegiate soccer with player-to-player contact the primary injury mechanism during games.7 Ankle ligament sprains, internal derangements of the knee and concussions were the most common injuries in women’s collegiate soccer.8
Based on the prevalence of soccer injuries, it is important for podiatrists to be aware of common treatments for soccer injuries as well as recommended rehabilitation after injury.
The single most common injury in soccer is the ankle sprain. Most ankle sprains are inversion sprains (85 percent), mainly involving the lateral ligament complex.9
In addition to standard radiographic views for ankle injuries (weightbearing AP, medial oblique and lateral ankle and foot), our office utilizes musculoskeletal ultrasound to aid in the diagnosis. We have found musculoskeletal ultrasound to be invaluable in the diagnosis of sports medicine foot and ankle injuries. Magnetic resonance imaging usually confirms ultrasound findings, especially when you cannot easily visualize or determine the degree of ligament tear. We will also use MRI when we suspect intra-articular, osteochondral lesions or when there is a history of ligamentous laxity due to chronic sprains in the absence of acute injury.
Podiatrists can manage minor acute lateral and medial ankle injuries conservatively with compression, analgesics, home exercises and time away from the playing field for a period of two to four weeks. For more severe injuries including anterior talofibular, calcaneofibular or deltoid ligament tears, or ruptures with or without intra-articular osteochondral defects, initial treatment will consist of immobilization and edema reduction. One may accomplish this by applying an Unna Boot soft cast for five days if the edema is severe. We will also use a CAM walker for immobilization for an additional four to six weeks. This will be followed by physical therapy twice a week for an additional six to eight weeks. Physical therapy, which includes proprioceptive coordinative training, helps with both injury prevention and rehabilitation, and is essential in returning injured players back to the field.11
The most common risk factor for ankle sprain in sports is history of a previous sprain.9 Our clinic dispenses an Air-Stirrup® Ankle Brace (Aircast) to soccer players suffering a moderate or severe sprain. They wear the brace during play for at least six months after an ankle injury. This simple treatment can mean the difference between patients being able to continue to play uninjured and having to withdraw from soccer entirely due to chronic, worsening instability or pain.
We commonly see soccer strains of the posterior tibial tendon, anterior tibial tendon, peroneal tendons, Achilles tendon and plantar fasciitis. Again, in these cases, treatment is symptomatic and includes compression sleeves, rest, ice, compounded topical anti-inflammatories and modified activity.12 In more severe or chronic cases, immobilization, bracing and taping can be effective as well as physical therapy.
For taping, we instruct our players on how to use RockTape for injury prevention and rehabilitation. During the 2008 Summer Olympics, taping came to the forefront when Olympians competing in sports ranging from volleyball to water polo sported a brightly colored athletic tape called Kinesio Tape®. In 2009, Rocktape (www.rocktape.com  ) became a major competitor to Kinesio. However, while one needs to be certified to promote and use Kinesio taping, this is not the case with Rocktape.
Rocktape has how-to videos on its Web site as well as a brochure packaged with each roll offering instructions on how to apply the tape. Rocktape also sells wholesale to podiatrists so patients can purchase this directly from your office rather than buying it somewhere else.
Rocktape primarily markets to athletes and our soccer players routinely respond favorably to this easy, inexpensive, treatment. Similar to Tensoplast® (formerly Elastoplast®), Rocktape is an elastic tape that one can use for support and compression. The best part is you can teach your patients how to do this themselves and the tape stays on for four to five days.
In addition to the aforementioned treatments of bracing, compression sleeves, taping and physical therapy, there are additional considerations for soccer players that can significantly reduce the likelihood of injury.
Soccer shoes are typically designed to fit tight for better feel and control of the ball. Unfortunately, too many players select shoes that are too narrow and/or too short, and this contributes to injury. When the fit is too tight, neuroma pain, bunion pain, hammertoe pain, heloma molle or heloma durum can occur. When the fit is too short, ingrown toenails, subungual hematoma, onychodystrophy, plantar fasciitis, turf toe and sesamoiditis can occur. An improperly fitting or excessively worn soccer shoe can cause ankle instability, sprains, strains or even fractures in an otherwise healthy foot.
The majority of soccer shoes are purchased online through recommendations from athletic trainers, sponsors, teammates or advertisers. The American Academy of Podiatric Sports Medicine (www.aapsm.org/  ) currently lists 94 recommended shoes for running and only four for soccer. It is shocking to me the lack of information available to patients to help them find appropriately fitting soccer shoes. Fortunately, this is an area of injury prevention that podiatrists can significantly impact. All that is required is applying the same principles for running shoes to selecting soccer shoes.
1. Size/fit. Easily 85 percent of patients whose feet are measured in our office are wearing the wrong size shoe. In those cases in which we cannot directly measure foot size in the office, we send patients to a running shoe store or other specialty shoe store to be properly measured and sized. One can subsequently apply this information to fitting soccer shoes.
Soccer cleat sizes do not indicate widths and this can make it difficult to obtain a good fit. Since many medium width cleats will run either wide or narrow, you can use a side-by-side comparison to identify volume differences among different pairs of shoes.
The Adidas Predator Absolion TRX TF has a narrow lasted cleat (see the cleat on the left of the photo at left) and the Nike Mercurial Victory II has a wide lasted cleat (see the cleat on the right of the photo at left). The differences in width are highlighted. Comparing the uppers, notice how the throatline (opening) of the Nike is so much wider than the Adidas. Also notice the difference in toebox shape and width. The Adidas is more tapered around the toes and the Nike is more rounded, accommodating a wider forefoot.
In evaluating the lower, you can also see how much wider the forefoot and waist are in the Nike than in the Adidas. If your patients are having difficulty finding the perfect fit, showing them this method should help. These principles also apply to other shoes (tennis, basketball, football, etc.) that only come in medium widths.
2. Design. There are soccer shoes designed for firm ground, hard ground, soft ground and indoor fields, and turf depending on the intended playing surface. Most non-professional players own both a pair of firm ground cleats and a pair of non-cleated turf shoes. Firm ground cleats have molded studs for traction and stability, and are the most common type of soccer shoe worn. Turf shoes have a firm rubber outsole with raised patterns on the outsole designed for indoor soccer or turf. Many players wear these different types of soccer shoes interchangeably. However, similar to snow versus road tires, each type is designed for a specific playing surface and should only be used on that surface.
3. Wear. Running shoe companies have emphasized the need for running shoe replacement after 500 miles of wear. Soccer players have no such advocate to help them determine when to replace their shoes. Players can easily sustain injury if the shoes are not replaced when they have been excessively worn. Again, similar to educating runners on running shoes, the podiatric physician or staff can teach patients how to evaluate their soccer shoes for excessive wear.
I always ask my patients who wear custom orthoses what sports they play. If soccer is one of their sports and they have biomechanical issues that could potentially contribute to a delay in healing or injury, I almost always prescribe custom orthoses for their soccer shoes. Soccer injuries for which I have found orthoses to be useful include plantar fasciitis, posterior tibial tendinitis, medial tibial stress syndrome, sesamoiditis and second metatarsophalangeal joint pre-dislocation syndrome.
The only challenge an orthosis may pose is fitting into a soccer shoe. Considerations such as a medial heel skive, inversion or minimal cast fill with prescription orthoses should first and foremost be based on patient pathology. Then one may proceed to consider modifications to a standard orthoses prescription to ensure fit into a soccer shoe. I prefer a soccer orthoses shell to be manufactured out of semi-rigid polypropylene. This makes it easy to modify (including grinding) in the office if necessary. Due to the low profile of a soccer shoe, I will prescribe a 8 to 10 mm heel cup depth, normal width, with or without a medial flange and a strip post. Alternatively, you can send the shoe with the orthoses prescription to the lab for an exact fit if you desire.
If the orthosis does not need additional forefoot padding, I will order the device without a top cover. Otherwise, I will extend the topcover to the sulcus to minimize excess forefoot bulk.
Soccer injuries are not unique from most other sports medicine injuries podiatric physicians diagnose and treat. What is somewhat unusual however is the lack of knowledge our patients have regarding soccer injury treatments and prevention. With the ever increasing numbers of new players to the sport, it is important that our offices and clinics develop protocols as well as patient education tools to minimize injury and maximize injury prevention in this popular American sport.
Dr. Sanders is an Adjunct Clinical Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University. She is in private practice in San Francisco. Dr. Sanders writes a monthly blog for Podiatry Today. For more information, please visit www.podiatrytoday.com/blogs/594  . Dr. Sanders also blogs at www.drshoe.wordpress.com  .
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