Time-trends and circumstances surrounding ankle injuries in men's professional football: an 11-year follow-up of the UEFA Champions League injury study

Comparison of Subjective and Biomechanical Outcomes Between Proprioceptive Training and Modified Broström-Gould Surgery for Chronic Ankle Instability: A Randomized Controlled Trial

Background

Both proprioceptive training and modified Broström-Gould surgery can improve ankle stability in patients with chronic ankle instability (CAI), but further biomechanical evaluation is necessary to determine the optimal treatment.

Purpose

To compare the clinical outcomes and biomechanical changes after proprioceptive training versus modified Broström-Gould surgery in patients with CAI.

Study Design

Randomized controlled trial; Level of evidence, 2.

Methods

A total of 56 patients with CAI were assigned randomly to either a nonoperative group (n = 28) who underwent 3 months of proprioceptive training or an operative group (n = 28) who underwent modified Broström-Gould surgery. Foot and Ankle Ability Measure (FAAM) scores, foot pressure during walking, center of pressure (COP) velocity, and time for the COP to reach the balance boundary (time to boundary [TTB]) during single-leg standing were collected before the intervention (baseline) and at 3, 6, and 12 months after the intervention. Two-way repeated-measures analysis of variance was used to compare group differences and changes over time.

Results

The nonoperative group had significant improvements from baseline in FAAM-Sports score and significantly decreased TTB in both the anterior-posterior and medial-lateral directions at all timepoints, while the operative group showed significant improvements only in FAAM-Sports scores and TTB and COP velocity in the anterior-posterior direction at 6 and 12 months postintervention. During walking, the nonoperative group had significantly increased peak force under the medial foot at 3 months, which dropped back to baseline levels at 12 months, while the operative group had significantly increased peak force under the medial midfoot and hindfoot that persisted until 12 months (P < .05).

Conclusion

In this study, both proprioceptive training and modified Broström-Gould surgery led to improved subjective functional scores, foot pressure distribution during walking, and postural stability during standing for patients with CAI but with different biomechanical patterns. Proprioceptive training led to an earlier recovery of sports function and better medial-lateral stability recovery, while surgery provided more persistent results.

Registration

ChiCTR1900023999 (Chinese Clinical Trial Registry).

A Rehabilitation Algorithm After Lateral Ankle Sprains in Professional Football (Soccer): An Approach Based on Clinical Practice Guidelines

Lateral ankle sprain (LAS) is one of the most common types of injury in professional football (soccer) players with high risk of recurrence. The rehabilitation after LAS in professional football players is often still time-based and relies on anecdotal experience of clinicans. There is still a lack of utilization of criteria-based rehabilitation concepts after LAS in professional football. The aims of this clinical commentary are (1) to critically discuss the need for criteria-based rehabilitation concepts after LAS in professional football players, (2) to highlight the current lack of these approaches and (3) to present a novel clinical guideline-based rehabilitation algorithm. Short time-loss (15 days) and high recurrence rate (17%) raise the question of trivialization of LAS in professional football. Despite consequences for many stakeholders involved (players, teams, clubs, insurers), there is still a lack of of criteria-based, step-by-step approaches. The use of a criteria-based rehabilitation approach might reduce the high recurrence rate after LAS in professional football players and will lead, in turn, to increased long-term player availability. Practical experiences of he authors demonstrate the feasibility of such an approach. The effectiveness of this novel rehabilitation algorithm remains to be evaluated in future studies. Level of Evidence: 5.

Return to Play Assessment After Lateral Ankle Sprains - German Male Elite Youth Football (Soccer) Academy Baseline Data

Background

Lateral ankle sprain (LAS) is one of the most common types of injury in football (soccer). Normative baseline data of performance tests for Return to Play (RTP) decision are still lacking.

Purpose

The primary aim of this study was to generate baseline values for uninjured elite youth football players for a multifactorial RTP assessment and compare with previously published data. A secondary aim was to investigate the use of the Limb Symmetry Index (LSI) as a method to determine whether an athlete passes a performance test or not.

Study Design

Observational Cohort study.

Methods

Baseline data of performance tests (Y-Balance [YBT-LQ], Heel Rise [HRT]; Singe Leg Squat [SLST]; Single Leg Drop Jump [SLDJ]; Side Hop [SHT]; Figure of 8 Hop [F-8]; Modified Agility T-Test [MAT]) were assessed in 20 elite youth football players, aged 16-21 years. Additionally, the traditional LSI (dividing the result of the non-dominant leg by the result of the dominant leg and multiplying by 100) and directionally corrected LSI (the worst value is divided by the better value and multiplied by 100) were calculated. The test values were compared to previously reported study results. LSI and side-to-side comparisons between dominant and non-dominant leg sides were analyzed using the Wilcoxon test.

Results

Male elite youth football players achieved better results in the dynamic performance tests (SHT, F-8, and MAT) compared to reference values of the cohorts previously described in the literature: YBT-LQ total score (cm) dominant (dom) 99.3±8.3, non-dominant (ND) 99.5±10.4; HRT (average number) dom. 27.1±5.4, ND 25.2±5.1); SLDJ height (cm) dom 15±5, ND 15±5 and contact time (sec) dom 0.29±0.08, ND 0.29±0.07, Reactive Strength Index (RSI) dom 0.52±0.12, ND 0.50±0.13); SHT (sec) dom 7.12±0.73, ND 7.39±0.93; F-8 (sec) dom 10.52±1.02, ND 10.37±1.04; and MAT (sec) 5.82±0.22. Directionally corrected LSI differed significantly from the traditional calculated LSI (p<0.05).

Conclusion

The findings of this study highlight the need to determine specific baseline data for RTP testing in male elite youth football players after LAS. The traditional LSI should not be used as a "stand alone method" for determining RTP. LSI calculations should consider the direction of asymmetry to determine passing a performance test or not.

Level of evidence

3b.

Time-loss injuries and illnesses at the FIFA world cup Qatar 2022

The study aimed to analyse incidence and characteristics of time-loss injuries and illnesses during the FIFA World Cup Qatar 2022. Of 838 male football players, 705 consented to participate. Team medical staff reported 82 time-loss injuries, corresponding to an injury event incidence of 5.6 injuries/1000 h of total exposure (95%CI 4.5 to 7.0 injuries/1000 h), with a median of 2 time-loss injury events per team (IQR, 1 to 4.5, range 0-7). The total injury burden was 103 (95% CI 61 to 152) days per 1000 h. Muscle/tendon injuries had the highest incidence of tissue types (48 cases, 3.3/1000 h (95% CI 2.5 to 4.4), and hamstring muscle injuries were the most frequent diagnosis (16 cases, incidence 1.1/1000 h, 95% CI 0.6 to 1.8). Match injury event incidence was 20.6/1000 h (15.0 to 27.7) and training injury event incidence was 2.1/1000 h (1.4 to 3.1). The majority (52%) of sudden-onset injuries were non-contact injuries, 40% direct contact and 8% indirect contact. We recorded 15 time-loss illnesses, corresponding to an illness event incidence of 1.1 per 1000 competition days, (95% CI: 0.6 to 1.8), and illness burden of 2.1 (1.0 to 3.4) days lost per 1000 competition days. The most common illness was respiratory infection (12 cases, 80%). Match injury event incidence was the lowest in any FIFA World Cup since injuries have been monitored.

Asymmetry in kinematics of dominant/nondominant lower limbs in central and lateral positioned college and sub-elite soccer players

Change of direction, stops, and pivots are among the most common non-contact movements associated with anterior cruciate ligament (ACL) injuries in soccer. By observing these dynamic movements, clinicians recognize abnormal kinematic patterns that contribute to ACL tears such as increased knee valgus or reduced knee flexion. Different motions and physical demands are observed across playing positions, which may result in varied lower limb kinematic patterns. In the present study, 28 college and sub-elite soccer players performed four dynamic motions (change of direction with and without ball, header, and instep kick) with the goal of examining the effect of on-field positioning, leg dominance, and gender in lower body kinematics. Motion capture software monitored joint angles in the knee, hip, and ankle. A three-way ANOVA showed significant differences in each category. Remarkably, centrally positioned players displayed significantly greater knee adduction (5° difference, p = 0.013), hip flexion (9° difference, p = 0.034), hip adduction (7° difference, p = 0.016), and dorsiflexion (12° difference, p = 0.022) when performing the instep kick in comparison to their laterally positioned counterparts. These findings suggest that central players tend to exhibit a greater range of motion when performing an instep kicking task compared to laterally positioned players. At a competitive level, this discrepancy could potentially lead to differences in lower limb muscle development among on-field positions. Accordingly, it is suggested to implement position-specific prevention programs to address these asymmetries in lower limb kinematics, which can help mitigate dangerous kinematic patterns and consequently reduce the risk of ACL injury in soccer players.

[Treatment of acute ankle distortion in footballers : Are we doing it particularly right or particularly wrong?]

BACKGROUND

Despite the high incidence of ankle sprains, the ideal treatment is controversial and a significant percentage of patients who have suffered an ankle sprain never fully recover. Even professional athletes are affected by this post-traumatic complication. There is strong evidence that permanent impairment after an ankle injury is often due to an inadequate rehabilitation and training program and too early return to sport.

THERAPY AND REHABILITATION

Therefore, athletes should start a criteria-based rehabilitation after ankle sprain and gradually progress through the programmed activities, including e.g. cryotherapy, edema reduction, optimal load management, range of motion exercises to improve ankle dorsiflexion and digital guidance, stretching of the triceps surae with isometric exercises and strengthening of the peroneus muscles, balance and proprioception training, and bracing/taping. The fact that this is professional sport does not exempt it from consistent, stage-appropriate treatment and a cautious increase in load. However, there are a number of measures and tools that can be used in the intensive care of athletes to improve treatment and results.

Epidemiology and management of ankle sprain injuries over seven seasons in an elite professional ballet company

OBJECTIVES

To investigate the epidemiology and management of ankle ligament sprains over seven seasons in a professional ballet company.

DESIGN

Descriptive epidemiology study.

METHODS

Medical attention injury, time-loss injury, and exposure data pertaining to 140 professional ballet dancers were prospectively recorded by Chartered Physiotherapists over seven seasons (2015/16-2021/22); a period including the COVID-19 global pandemic.

RESULTS

Sixty-nine ankle sprains (46 time-loss) in 45 dancers (32 %) were recorded: 51 sprains were classified as grade I, 15 were classified as grade II, and three were classified as grade III; 53 sprains affected only one ligament, whilst 16 were multi-ligament sprains. For time-loss injuries, median time-loss durations varied by grading (I - 31 days, II - 54 days, and III - 147 days) and the number of ligaments affected (one - 31 days, two - 54 days, three - 134 days, four - 137 days), with time-loss ranging from 1 to 188 days. Of the 46 time-loss ankle sprains, eight were mild, nine were moderate, and 29 were severe. The incidence rate (injuries·1000 h-1) of medical attention ankle sprains was 0.073 (95 % CI: 0.046 to 0.117) in male dancers and 0.101 (95 % CI: 0.069 to 0.148) in female dancers, and the incidence of time-loss ankle sprains was 0.044 (95 % CI: 0.024 to 0.080) in male dancers and 0.064 (95 % CI: 0.040 to 0.103) in female dancers. No significant effect of sex was observed on either medical attention (p = .304) or time-loss (p = .327) ankle sprain incidence rates. Ten percent of dancers sustained multiple sprains across the seven seasons. Fifty and 39 % of ankle sprains in female and male dancers, respectively, were preceded by a history of ankle sprains. Jumping and landing (30 sprains) and non-dance movements (16 sprains) were the most common inciting movements. Bone bruising and synovitis were the most common concurrent pathologies.

CONCLUSIONS

Ankle sprains placed a considerable burden on the ballet company studied. These time-loss durations specified by number and grade of ligament sprain, injury history, and secondary pathologies can guide return-to-dance rehabilitation pathways.

Chronic lateral ankle ligament instability - Current evidence and recent management advances

Lateral ankle sprain is a common injury with a substantial negative impact on physical function, quality of life and health economic burden. Chronic lateral ankle instability (CLAI) as a sequela of lateral ankle sprain can lead to the development of posttraumatic ankle osteoarthritis in the long term. In this article, we explore the epidemiology, burden and definition of CLAI for the appropriate clinical assessment and imaging evaluation of patients with lateral ankle sprain and CLAI. Following that, recent advances and evidence on management of CLAI is critically distilled and summarized.

[Time-loss and recurrence rates after lateral ankle ligament sprains in male elite football players: summary of a systematic review and meta-analysis]

A literature search was conducted to systematically review and meta-analyse time-loss and recurrence rates of lateral ankle sprains (LAS) in male professional football players. Six electronic databases were screened separately for time-loss and recurrence rates after lateral ankle sprains in elite football players. A total of 13 (recurrence) and 12 (time-loss) studies met the previously defined inclusion criteria. The total sample size of the recurrence studies was 36.201 participants (44.404 overall initial injuries, 7944 initial ankle sprain (AS) injuries, 1193 recurrent AS injuries). 16.442 professional football players (4893 initial AS injuries, 748 recurrent AS injuries) were subsequently meta-analysed. A recurrence rate of 17.11% (95% CI: 13.31-20.92%; df=12; Q=19.53; I2=38.57%) was determined based on the random-effects model. A total of 7736 participants were part of the time-loss studies (35.888 total injuries, 4848 total ankle injuries; 3370 AS injuries). Out of the 7736 participants, 7337 participants met the inclusion criteria with a total of 3346 AS injuries. The average time-loss was 15 days (weighted mean: 15.92, median: 14.95, min: 9.55; max: 52.9). A priori, we determined considerable heterogeneity (CI: 18.15-22.08; df=11; Q=158; I2=93%). There is an average time-loss of 15 days per LAS and a recurrence rate of 17%. LAS is one of the most common types of injury with high recurrence rates in professional football players. The high recurrence rates and long-term consequences show the necessity for research in the field of LAS in elite football. However, heterogeneous data lead to difficulties regarding the aspect of comparability.

Single-Leg Loading Test to Predict Time to Jog and Return to Sports after Acute Lateral Ankle Sprain in Competitive Athletes

In a previous study, the utility of a single-leg loading (SLL) test after acute lateral ankle sprain (LAS) was reported. However, whether the severity level assessed by the SLL test is associated with the time to jog and return to sports (RTS) remains unclear. Therefore, this study aimed to examine whether the time to jog and RTS differ depending on the severity level. A total of 240 athletes after sustaining acute LAS were included in this study. The SLL test was performed at the first visit, and the patients were classified into four levels (Levels 1-4). The Steel-Dwass multiple comparison method and multiple regression analysis was performed to verify whether the SLL test can predict the time to jog and RTS. On examining the relationship between the severity levels assessed by the SLL test and time to jog and RTS, significant differences were found among almost all the severity levels. Moreover, the multiple regression analysis revealed that only the SLL test showed a significant correlation with both the time to jog and RTS. This study suggested that the time to jog and RTS can be predicted by conducting the SLL test for acute LAS and dividing the severity into four levels.

In Different Gender Groups, What Is the Impact of the Fibular Notch on the Severity of High Ankle Sprain: A Retrospective Study of 360 Cases

OBJECTIVES

The role of the distal tibiofibular ligament in the occurrence of high ankle sprain (HAS) has been widely studied. But previous studies have overlooked the physiological and anatomical differences between males and females and have not further refined gender. Therefore, the impact of the anatomical morphology of fibular notch (FN) on HAS in different genders is still unclear. This study aimed to explore the impact of different types of FN on the severity of HAS and to estimate the prognosis of patients with HAS while excluding anatomical differences caused by gender.

METHODS

One hundred and eighty patients with HAS were included in this study as the experimental group (i.e., HAS group). They were further divided into four groups according to gender and FN depth, with deep concave FN ≥ 4 mm and shallow flat FN < 4 mm. Another 180 normal individuals were set as the control group. The FN morphological indicators, tibiofibular distance (TFD), and ankle mortise indexes were measured and compared with those in HAS group. The independent t-test was used to compare continuous variables between groups, the intraclass correlation coefficient (ICC) was used to analyze the reliability of intra-observer measurement, and the Pearson correlation coefficient was used to verify the correlation between FN and the severity of HAS.

RESULTS

In males with shallow flat type, the measurements of anterior tibiofibular distance (aTFD), middle tibiofibular distance (mTFD), posterior tibiofibular distance (pTFD), front ankle mortise width (fAMW), middle ankle mortise width (mAMW), posterior ankle mortise width (pAMW), and depth of ankle mortise (DOAM) in HAS group were significantly larger than those in normal group (p < 0.05). In male patients with deep concave type, the measurements of aTFD, mTFD, fAMW, mAMW, and DOAM were significantly larger than those in normal group (p < 0.05). Among female patients with shallow flat type, the measurements of aTFD, mTFD, pTFD, fAMW, mAMW, pAMW, and DOAM were found to be significantly larger than those in normal group (p < 0.05). Among female patients with deep concave type, the measurements of mTFD, pTFD, fAMW, mAMW, and DOAM were found to be significantly larger than those of the normal group (p < 0.05). The depth of FN was negatively correlated with TFD, and the AOFAS score of patients with shallow flat type was significantly lower than that of patients with deep concave type after treatment (p < 0.05).

CONCLUSIONS

In different gender groups, compared with the normal controls, the TFD and partial ankle mortise indices were significantly different in HAS patients. Moreover, FN depth was negatively correlated with TFD, and the AOFAS score of shallow flat patients was significantly lower than that of deep concave patients. These suggested that shallow flat FN may be associated with more severe distal tibiofibular ligament injury and ankle mortise widening, leading to poorer prognosis. This should be taken seriously in clinical practice.

Epidemiology of Injuries in Professional and Amateur Football Men (Part II)

Background (1): Men's football is a physically demanding contact sport that involves intermittent bouts of sprinting, jogging, walking, jumping and changes of direction. The physical demands of the game vary by level of play (amateur club, sub-elite and open club or international), but injury rates at all levels of the men's football game remain the highest of all sports. Objective: The aim of this study is to conduct a systematic review of data from the epidemiological literature regarding the profile, severity and mechanisms of injuries and the frequency of recurrent injuries in professional and amateur football players. Methods (2): A systematic review, according to PRISMA guidelines, was performed up to June 2023 in the databases of PubMed, Web of Science, Google academic, Google scholar and the Diva portal. Twenty-seven studies that reported data on the type, severity, recurrence and mechanisms of injury in professional and amateur men's football were selected and analyzed. Two reviewers independently audited data and assessed the study quality using the additional and adapted version of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement and the Newcastle Ottawa Scale (NOS) to assess risk of bias for the quality of external validity. Results (3): In professional male football players, the mean prevalence of muscle/tendon injuries was 39.78%, followed by joint and ligament injuries-21.13%, contusions-17.86%, and fractures-3.27%, and for amateur football players, the prevalence's were 44.56% (muscle/tendon injuries), 27.62% (joint and ligament injuries), 15.0% (contusions) and 3.05% (fracture), respectively. The frequency of traumatic injuries was higher in amateur football players (76.88%) compared to professional football players (64.16%), the situation being reversed in the case of overuse injuries: 27.62% in professional football players and 21.13% in amateur football players. Most contact injuries were found in professional footballers (50.70%), with non-contact injuries predominating in amateur footballers (54.04%). The analysis of the severity of injuries showed that moderate injuries dominated in the two categories of footballers; the severe injuries in amateur footballers exceeded the severe injuries recorded in professional footballers by 9.60%. Recurrence proportions showed an inverse relationship with the level of play, being higher in amateur footballers (16.66%) compared to professional footballers (15.25%). Conclusions (4): Football-related injuries have a significant impact on professional and amateur football players and their short- and long-term health status. Knowing the frequency of severe diagnoses, such as strains, tears and cramps of the thigh muscles, ankle ligament sprains and hip/groin muscle strain requires the establishment of adequate programs to prevent them, especially in amateur football players, who are more prone to serious injuries.

Does mechanical loading restore ligament biomechanics after injury? A systematic review of studies using animal models

BACKGROUND

Mechanical loading is purported to restore ligament biomechanics post-injury. But this is difficult to corroborate in clinical research when key ligament tissue properties (e.g. strength, stiffness), cannot be accurately measured. We reviewed experimental animal models, to evaluate if post-injury loading restores tissue biomechanics more favourably than immobilisation or unloading. Our second objective was to explore if outcomes are moderated by loading parameters (e.g. nature, magnitude, duration, frequency of loading).

METHODS

Electronic and supplemental searches were performed in April 2021 and updated in May 2023. We included controlled trials using injured animal ligament models, where at least one group was subjected to a mechanical loading intervention postinjury. There were no restrictions on the dose, time of initiation, intensity, or nature of the load. Animals with concomitant fractures or tendon injuries were excluded. Prespecified primary and secondary outcomes were force/stress at ligament failure, stiffness, laxity/deformation. The Systematic Review Center for Laboratory animal Experimentation tool was used to assess the risk of bias.

RESULTS

There were seven eligible studies; all had a high risk of bias. All studies used surgically induced injury to the medial collateral ligament of the rat or rabbit knee. Three studies recorded large effects in favour of ad libitum loading postinjury (vs. unloading), for force at failure and stiffness at 12-week follow up. However, loaded ligaments had greater laxity at initial recruitment (vs. unloaded) at 6 and 12 weeks postinjury. There were trends from two studies that adding structured exercise intervention (short bouts of daily swimming) to ad libitum activity further enhances ligament behaviour under high loads (force at failure, stiffness). Only one study compared different loading parameters (e.g. type, frequency); reporting that an increase in loading duration (from 5 to 15 min/day) had minimal effect on biomechanical outcomes.

CONCLUSION

There is preliminary evidence that post-injury loading results in stronger, stiffer ligament tissue, but has a negative effect on low load extensibility. Findings are preliminary due to high risk of bias in animal models, and the optimal loading dose for healing ligaments remains unclear.

The Burden of the "Simple Ankle Sprains": A Review of the Epidemiology and Long-Term Impact

Lateral ankle sprain (LAS) is not as simple as it was believed to be as it has substantial negative impacts on the active sporting population. The negative impact on physical function, quality of life (QoL) and economic burden is significant with increased risk of reinjury, development of chronic lateral ankle instability and posttraumatic ankle osteoarthritis resulting in functional deficits, decreased QoL and chronic disabilities. Economic burden from a societal perspective demonstrated notably higher indirect costs from productivity loss. Preventative interventions with early surgery for a selective cohort of active sporting population may be considered to mitigate morbidities associated with LAS.

Acute Ankle Sprain in Elite Athletes: How to Get Them Back to the Game?

Despite the high frequency of ankle sprains, the ideal management is controversial, and a significant percentage of patients sustaining an ankle sprain never fully recover. There is strong evidence that residual disability of ankle joint injury is often caused by an inadequate rehabilitation and training program and early return to sports. Therefore, the athlete should start their criteria-based rehabilitation and gradually progress through the programmed activities, including cryotherapy, edema relief, optimal weight-bearing management, range of motion exercises for ankle dorsiflexion improvement, triceps surae stretching, isometric exercises and peroneus muscles strengthening, balance and proprioception training, and bracing/taping.

Rehabilitation of a lateral ankle reconstruction in a male professional football player - A narrative case report

OBJECTIVES

Lateral ankle sprains involving the ATFL and CFL are common injuries in football with a high recurrence rate. There is a lack of research to guide post-operative rehabilitation of football players following lateral ligament ankle reconstructive surgery. This narrative case report discusses the management of a lateral ligament reconstruction in a male professional football player.

METHODS

A 25-year-old professional footballer underwent a lateral ankle reconstruction following recurrent lateral ankle sprains leading to an unstable ankle.

RESULTS

Following 11-weeks of rehabilitation the player was cleared to return to full-contact training. The player competed in his first competitive match 13-weeks post-injury and completed a 6-month full-training block, without episodes of pain or instability.

CONCLUSION

This case report illustrates the rehabilitation process of a football player following a lateral ankle ligament reconstruction within a timeframe expected in elite sport.

Physical Examination of Ankle Sprain and Ankle Instability: Can We Really Divide It into Low and High Ankle Sprains?

Lateral ankle ligament sprains and syndesmotic injuries are two different entities. However, they may be combined under the same spectrum depending on the arch of violence during the injury. Currently, the clinical examination has a limited value in the differential diagnosis between an acute anterior talofibular ligament rupture and a syndesmotic high ankle sprain. However, its use is indispensable for raising a high index of suspicion for detecting these injuries. Based on the mechanism of injury, clinical examination plays an essential role in guiding further imaging and early diagnosis of low/high ankle instability.

Kinesiophobia, self-reported ankle function, and sex are associated with perceived ankle instability in college club sports athletes with chronic ankle instability

OBJECTIVE

To investigate the association between sex, self-reported ankle function, pain intensity, kinesiophobia, and perceived ankle instability in athletes with chronic ankle instability (CAI).

DESIGN

Cross-Sectional Study.

SETTING

University.

PARTICIPANTS

College club sports athletes with CAI (n = 42).

MAIN OUTCOME MEASURES

Relationships with the Cumberland Ankle Instability Tool (CAIT) score and the Tampa Scale for Kinesiophobia-11 (TSK-11), the Foot and Ankle Ability Measure (FAAM), sex (0: male, 1: female), and ankle pain intensity by the Numeric Rating Scale were explored with multiple regression analysis.

RESULTS

The regression model explained 50.3% of the variance of the CAIT score (P < 0.001), and the TSK-11 score (B = -0.382, P = 0.002), the FAAM sports subscale score (B = 0.122, P = 0.038), and sex (B = -2.646, P = 0.031) were significant independent variables for the CAIT score (P < 0.001), while pain intensity was not significant (B = -0.182, P = 0.504). These results indicated that higher TSK-11 score, lower FAAM sports subscale score, and being female were related to lower CAIT score.

CONCLUSIONS

Kinesiophobia related to perceived instability along with self-reported function and sex in athletes with CAI. Clinicians should assess the psychological aspects of athletes with CAI.

Epidemiological Characteristics of Foot and Ankle Injuries in 2 Professional Ballet Companies: A 3-Season Cohort Study of 588 Medical Attention Injuries and 255 Time-Loss Injuries

Background

The foot and ankle are often reported as the most common sites of injury in professional ballet dancers; however, epidemiological research focusing on foot and ankle injuries in isolation and investigating specific diagnoses is limited.

Purpose

To investigate the incidence rate, severity, burden, and mechanisms of foot and ankle injuries that (1) required visiting a medical team (medical attention foot and ankle injuries; MA-FAIs) and (2) prevented a dancer from fully participating in all dance-related activities for at least 24 hours after the injury (time-loss foot and ankle injuries; TL-FAIs) in 2 professional ballet companies.

Study Design

Descriptive epidemiological study.

Methods

Foot and ankle injury data across 3 seasons (2016-2017 to 2018-2019) were extracted from the medical databases of 2 professional ballet companies. Injury-incidence rate (per dancer-season), severity, and burden were calculated and reported with reference to the mechanism of injury.

Results

A total of 588 MA-FAIs and 255 TL-FAIs were observed across 455 dancer-seasons. The incidence rates of MA-FAIs and TL-FAIs were significantly higher in women (1.20 MA-FAIs and 0.55 TL-FAIs per dancer-season) than in men (0.83 MA-FAIs and 0.35 TL-FAIs per dancer-season) (MA-FAIs, P = .002; TL-FAIs, P = .008). The highest incidence rates for any specific injury pathology were ankle impingement syndrome and synovitis for MA-FAIs (women 0.27 and men 0.25 MA-FAIs per dancer-season) and ankle sprain for TL-FAIs (women 0.15 and men 0.08 TL-FAIs per dancer-season). Pointe work and jumping actions in women and jumping actions in men were the most common mechanisms of injury. The primary mechanism of injury of ankle sprains was jumping activities, but the primary mechanisms of ankle synovitis and impingement in women were related to dancing en pointe.

Conclusion

The results of this study highlight the importance of further investigation of injury prevention strategies targeting pointe work and jumping actions in ballet dancers. Further research for injury prevention and rehabilitation strategies targeting posterior ankle impingement syndromes and ankle sprains are warranted.

Concussion increases within-player injury risk in male professional rugby union

OBJECTIVES

To assess within-player change in injury risk and between-player subsequent injury risk associated with concussive and common non-concussive injuries in professional rugby union.

METHODS

This prospective cohort study in Welsh professional male rugby union analysed within-player and between-player injury risk for five common injuries: concussion, thigh haematoma, hamstring muscle strain, lateral ankle sprain and acromioclavicular joint sprain. Survival models quantified within-player injury risk by comparing precommon (before) injury risk to postcommon (after) injury risk, whereas between-player subsequent injury risk was quantified by comparing players who had sustained one of the common injuries against those who had not sustained the common injury. HRs and 95% CIs were calculated. Specific body area and tissue type were also determined for new injuries.

RESULTS

Concussion increased the within-player overall injury risk (HR 1.26 (95% CI 1.11 to 1.42)), elevating head/neck (HR 1.47 (95% CI 1.18 to 1.83)), pelvic region (HR 2.32 (95% CI 1.18 to 4.54)) and neurological (HR 1.38 (95% CI 1.08 to 1.76)) injury risk. Lateral ankle sprains decreased within-player injury risk (HR 0.77 (95% CI 0.62 to 0.97)), reducing head/neck (HR 0.60 (95% CI 0.39 to 0.91)), upper leg and knee (HR 0.56 (95% CI 0.39 to 0.81)), joint and ligament (HR 0.72 (95% CI 0.52 to 0.99)) and neurological (HR 0.55 (95% CI 0.34 to 0.91)) injury risk. Concussion (HR 1.24 (95% CI 1.10 to 1.40)), thigh haematomas (HR 1.18 (95% CI 1.04 to 1.34)) and hamstring muscle strains (HR 1.14 (95% CI 1.01 to 1.29)) increased between-player subsequent injury risk.

CONCLUSION

Elevated within-player injury risk was only evident following concussive injuries, while lateral ankle sprains reduced the risk. Both concussion and ankle injuries altered head/neck and neurological injury risk, but in opposing directions. Understanding why management of ankle sprains might be effective, while current concussion management is not at reducing such risks may help inform concussion return to play protocols.

Time-loss and recurrence of lateral ligament ankle sprains in male elite football: A systematic review and meta-analysis

A literature search was conducted to systematically review and meta-analyze time-loss and recurrence rate of lateral ankle sprains (LAS) in male professional football players. Six electronic databases (PubMed, Scopus, Web of Science, PEDRO, CINAHL, and Cochrane) were searched independently, separately both for time-loss and recurrence from inception until April 30, 2021. In addition, reference lists were screened manually to find additional literature. Cohort studies, case reports, case-control studies and RCT in English language of male professional football players (aged more than 16 years) for which data on time-loss or recurrence rates of LAS were available were included. A total of 13 (recurrence) and 12 (time-loss) studies met the inclusion criteria. The total sample size of the recurrence studies was 36,201 participants (44,404 overall initial injuries; 7944 initial ankle sprain [AS] injuries, 1193 recurrent AS injuries). 16,442 professional football players (4893 initial AS injuries; 748 recurrent AS injuries) were meta-analyzed. A recurrence rate of 17.11% (95% CI: 13.31-20.92%; df = 12; Q = 19.53; I² = 38.57%) based on the random-effects model was determined. A total of 7736 participants were part of the time-loss studies (35,888 total injuries; 4848 total ankle injuries; 3370 AS injuries). Out of the 7736 participants, 7337 participants met the inclusion criteria with a total of 3346 AS injuries. The average time-loss was 15 days (weighted mean: 15.92; median: 14.95; min: 9.55; max: 52.9). We determined a priori considerable heterogeneity (CI: 18.15-22.08; df = 11; Q = 158; I² = 93%), so that the data on time-loss are only presented descriptively. There is an average time-loss of 15 days per LAS and a recurrence rate of 17%. LAS is one of the most common types of injury with higher recurrence rates than ACL injuries (9%-12%) in professional football players. Nevertheless, the focus of research in recent years has been mostly on ACL injuries. However, the high recurrence rates and long-term consequences show the necessity for research in the field of LAS in elite football. Yet, heterogeneous data lead to difficulties concerning the aspect of comparability.

Injury Burden in Professional European Football (Soccer): Systematic Review, Meta-Analysis, and Economic Considerations

OBJECTIVE

We performed a systematic review and meta-analysis to evaluate the injury burden and the related economic cost in European professional male football players.

DATA SOURCES

Multiple database research was performed up to August 5, 2022 (PubMed, EMbase, Scopus, Cochrane Library), including only studies that reported severity in the number of days of absence for each injury, incidence reported in the number of injuries/1000 hours, or reported number of injuries and exposure time and adult male football players, professionals from European clubs. Two reviewers extracted data and assessed paper quality with the Strengthening the Reporting of Observational Studies in Epidemiology statement and the Newcastle-Ottawa Scale.

MAIN RESULTS

Twenty-two studies have reported incidence, severity, and burden of injuries in professional football. The highest injury burden was found for ligament-joint injuries (37.9 days/1000 hours; 222 397 €/1000 hours) and for muscle injuries (34.7 days/1000 hours; 203 620 €/1000 hours). Injury locations with high burden were knee injuries (34.8 days/1000 hours; 20 4206 €/1000 hours)-mainly anterior cruciate ligament injuries (14.4 days/1000 hours; 84 499 €/1000 h)-followed by thigh injuries (25.0 days/1000 hours; 146 700 €/1000 hours), hamstrings injuries (15.4 days/1000 hours; 90 367 €/1000 hours), hip-and-groin injuries (16.1 days/1000 hours; 94 475 €/1000 hours), primarily adductor muscles injuries (9.4 days/1000 hours; 55 159€/1000 hours), and ankle injuries (13.1 days/1000 h; 76 871 €/1000 hours) with ankle sprains (7.4 days/1000 hours; 43 423 €/1000 hours).

CONCLUSIONS

Being exposed to injury risk has serious consequences for individual and club performance and economy. This review identified the most relevant targets in injury management, compared their injury data with reference values, and provided economic evidence when trying to gain buy-in from the key decision makers.

Biomechanical Characteristics of the Support Leg During Side-Foot Kicking in Soccer Players With Chronic Ankle Instability

Background:

Chronic ankle instability (CAI) in soccer players can increase the risk of recurrent ankle varus sprains and damage the articular surface of the ankle joint, thus increasing the risk of osteoarthritis. It is important to understand the biomechanical characteristics of the support leg during kicking in soccer players with CAI.

Purpose/Hypothesis:

The purpose of this study was to clarify the kinematics of the kicking motion of soccer players with CAI. It was hypothesized that at the point before ball contact when the support leg makes flat-foot contact with the ground, soccer players with CAI will land with ankle inversion in the support leg during a side-foot kick compared with players without CAI.

Study Design:

Controlled laboratory study.

Methods:

The study cohort included 19 male college soccer players (mean age, 20.5 ± 0.9 years) with greater than 8 years of soccer experience who were recruited from August 2019 to March 2020. Of these athletes, 10 had CAI and 9 had no CAI in the support leg, as diagnosed according to the Cumberland Ankle Instability Tool. Kinematic data for the trunk, hip, knee, and foot of the support leg during a side-foot kick were obtained using a 3-dimensional, motion-analysis system. The Mann-Whitney U test or Student t test was selected to identify differences in variables between the CAI and non-CAI groups.

Results:

There were no significant differences in physical characteristics between the CAI and non-CAI groups. At the point when the support leg made flat-foot contact with the ground, the players with CAI had more eversion of the hindfoot with respect to the tibia (-28.3° ± 12.1° vs -13.9° ± 14.2°; P = .03), a more varus alignment of the knee (26.0° ± 10.7° vs 13.7° ± 10.5°; P = .03), and a lower arch height index (0.210 ± 0.161 vs 0.233 ± 0.214; P = .046) compared with non-CAI players.

Conclusion:

Significant differences between players with and without CAI were seen in the support leg kinematics at flat-foot contact with the ground during the kicking cycle.

Clinical Relevance:

The biomechanical alignment of the support leg during a side-foot kick in players with CAI may reflect a subconscious attempt to avoid inversion of the foot and further ankle sprains.

Injury prevention programs that include balance training exercises reduce ankle injury rates among soccer players: a systematic review

QUESTION

What is the effect of injury prevention programs that include balance training exercises on the incidence of ankle injuries among soccer players?

DESIGN

Systematic review of randomised trials with meta-analysis.

PARTICIPANTS

Soccer players of any age, sex or competition level.

INTERVENTIONS

The experimental intervention was an injury prevention program that included balance training exercises. The control intervention was the soccer team's usual warm-up program.

OUTCOME MEASURES

Exposure-based ankle injury rates.

RESULTS

Nine articles met the inclusion criteria. The pooled results of injury prevention programs that included balance training exercises among 4,959 soccer players showed a 36% reduction in ankle injury per 1,000 hours of exposure compared to the control group with an injury risk ratio (IRR) of 0.64 (95% CI 0.54 to 0.77). The pooled results of the Fédération Internationale de Football Association (FIFA) injury prevention programs caused a 37% reduction in ankle injury (IRR 0.63, 95% CI 0.48 to 0.84) and balance-training exercises alone cause a 42% reduction in ankle injury (IRR 0.58, 95% CI 0.41 to 0.84).

CONCLUSIONS

This meta-analysis demonstrates that balance exercises alone or as part of an injury prevention program decrease the risk of ankle injuries. PROSPERO CRD42017054450.

Misencoding of ankle joint angle control system via cutaneous afferents reflex pathway in chronic ankle instability

This study aimed to investigate how the cutaneous reflexes in the peroneus longus (PL) muscle are affected by changing the ankle joint position in patients with chronic ankle instability (CAI). We also investigated the correlation between the degree of reflex modulation and angle position sense of the ankle joint. The participants were 19 patients with CAI and 20 age-matched controls. Cutaneous reflexes were elicited by applying non-noxious electrical stimulation to the sural nerve at the ankle joint in the neutral standing and eversion/inversion standing positions. The suppressive middle latency cutaneous reflex (MLR; ~ 70-120 ms) and angle position sense of the ankle joint were assessed. During neutral standing, the gain of the suppressive MLR was more prominent in the CAI patients than in controls, although no significant difference was seen during 30° inversion standing. In addition, the ratios of the suppressive MLR and background electromyography in a neutral position were significantly larger than those at the 15°, 25°, and 30° inversion positions in CAI patients. No such difference was seen in control individuals. Furthermore, the correlations between reflex modulation degree and position sense error were quite different in CAI patients compared to controls. These findings suggest that the sensory-motor system was deteriorated in CAI patients due to changes in the PL cutaneous reflex pathway excitability and position sense of the ankle joint.

Injuries in elite level male beach soccer players: a prospective three year study

OBJECTIVES

The aim of this study was to investigate the incidence and characteristics of match and training injuries in elite-level national male beach soccer players.

METHOD

The incidence, mechanism, location, type, severity, and burden of injuries of the Turkish national beach soccer team were recorded between 2017 and 2019.

RESULTS

A total of 136 injuries occurred during the study period. Total injury incidence was 238.9 injuries/1,000 match hours (MHs) and 37.7 injuries/1,000 training hours (THs) (p < 0.001). Twenty-seven injuries led to time-loss, and the incidences for match and training injuries were 36.7 and 7.9 per 1,000 hours, respectively. Of medical attention injuries (MAI) caused by trauma, 54.6% (n = 53) were due to another player and, 60.9% (n = 14) of time-loss injuries (TLI) caused by trauma were due to non-contact trauma (p < 0.001). While 82% (n = 91) of training injuries occurred in lower extremities, 29% (n = 9) of match injuries occurred in the head/neck region (p < 0.001). Head injury incidence was 45.9 per 1,000 match hours. Of MAI, 50% (n = 57) were contusion, and 32.1% (n = 9) of TLI were strain (p < 0.001). Also, the most common injury subtype was foot/toe contusion during match and training (19.4%; n = 6, 27.9%; n = 31, respectively). The majority of injuries 91.9% (n = 125) had slight severity.

CONCLUSION

Head trauma, tendon injury, and foot/toe contusion are important for clinical practice in beach soccer. Protective measures (rule regulation, use of protective equipment, etc.) should be considered to prevent these injuries.

Higher risk of ACL rupture in amateur football compared to professional football: 5-year results of the 'Anterior cruciate ligament-registry in German football'

PURPOSE

Anterior cruciate ligament (ACL) injuries are a common severe type of football injury at all levels of play. A football-specific ACL registry providing both prospective ACL injury data according to the skill level and risk factors for ACL injury is lacking in the literature.

METHODS

This study is based on the prospective 'ACL registry in German Football' implemented in the 2014-15 season. Professional (1st-3rd league), semi-professional (4th-6th league) and amateur leagues (7th league) were analysed regarding the incidence and risk factors for ACL injuries. Injuries were registered according to the direct reports of the injured players to the study office and double-checked via media analysis. After injury registration, the players received a standardised questionnaire. Data were analysed from the 2014-15 to the 2018-19 football season.

RESULTS

Overall, 958 ACL injuries were registered during the 5-year study period. The incidence of ACL injuries was highest in amateur football (0.074/1000 h football exposure) compared to professional (0.058/1000 h; p < 0.0001) and semi-professional football (0.043/1000 h; p < 0.0001). At all skill levels, match incidence (professional: 0.343; semi-professional: 0.249; amateur: 0.319) was significantly higher than training incidence (professional: 0.015; semi-professional: 0.004; amateur: 0.005). Major risk factors were previous ACL injury (mean: 23.3%), other knee injuries (mean: 19.3%) and move to a higher league (mean: 24.2%).

CONCLUSION

This sports-specific ACL registry provides detailed information on the incidence and risk factors for ACL injuries in football over five years. Risk factors are skill level, match exposure, move to a higher league and previous knee injury. These factors offer potential starting points for screening at-risk players and applying targeted prevention.

LEVEL OF EVIDENCE

II.

Foot and ankle Osteoarthritis and Cognitive impairment in retired UK Soccer players (FOCUS): protocol for a cross-sectional comparative study with general population controls

INTRODUCTION

Professional footballers commonly experience sports-related injury and repetitive microtrauma to the foot and ankle, placing them at risk of subsequent chronic pain and osteoarthritis (OA) of the foot and ankle. Similarly, repeated heading of the ball, head/neck injuries and concussion have been implicated in later development of neurodegenerative diseases such as dementia. A recent retrospective study found that death from neurodegenerative diseases was higher among former professional soccer players compared with age matched controls. However, well-designed lifetime studies are still needed to provide evidence regarding the prevalence of these conditions and their associated risk factors in retired professional football players compared with the general male population.

OBJECTIVES

To determine whether former professional male footballers have a higher prevalence than the general male population of: (1) foot/ankle pain and radiographic OA; and (2) cognitive and motor impairments associated with dementia and Parkinson's disease. Secondary objectives are to identify specific football-related risk factors such as head impact/concussion for neurodegenerative conditions and foot/ankle injuries for chronic foot/ankle pain and OA.

METHODS AND ANALYSIS

This is a cross-sectional, comparative study involving a questionnaire survey with subsamples of responders being assessed for cognitive function by telephone assessment, and foot/ankle OA by radiographic examination. A sample of 900 adult, male, ex professional footballers will be recruited and compared with a control group of 1100 age-matched general population men between 40 and 100 years old. Prevalence will be estimated per group. Poisson regression will be performed to determine prevalence ratio between the populations and logistic regression will be used to examine risk factors associated with each condition in footballers.

ETHICS AND DISSEMINATION

This study was approved by the East Midlands-Leicester Central Research Ethics Committee on 23 January 2020 (REC ref: 19/EM/0354). The study results will be disseminated at national and international meetings and submitted for peer-review publication.

Exercise-based rehabilitation reduces reinjury following acute lateral ankle sprain: A systematic review update with meta-analysis

Research questions

1) Do exercise-based rehabilitation programs reduce re-injury following acute ankle sprain?; 2) Is rehabilitation effectiveness moderated by the exercise’s therapeutic quality, content and volume?

Methods

This systematic review with meta-analysis (PROSPERO: CRD42020210858) included randomized controlled trials in which adults who sustained an acute ankle sprain received exercise-based rehabilitation as an intervention. Databases CINAHL, Web of Science, SPORTDiscus, Cochrane Central Register of Controlled Trials, PEDro and Google Scholar were searched for eligible articles (last search: March 2021). ROB II screening tool by Cochrane was used to assess risk of bias and the i-CONTENT tool was used to assess quality of interventions. Both qualitative analysis and quantitative data synthesis were performed.

Results

Fourteen randomized controlled trials comprising 2182 participants were included. Five studies were judged overall low risk of bias and i-CONTENT assessment showed poor to moderate therapeutic quality of exercise across all included articles. Pooled data found significant reductions in re-injury prevalence at 12 months, in favour of the exercise-based rehabilitation group vs usual care (OR: 0.60; 95%CI: 0.36 to 0.99). Pooled data for re-injury incidence showed not-significant results (MD: 0.027; 95%CI: -2.14 to 2.19). Meta-regression displayed no statistically significant association between training volume and odds of re-injury (r = -0.00086; SD: 0.00057; 95%CI: -0.00197 to 0.00025). Results from patient-reported outcomes and clinical outcomes were inconclusive at 1 month, 3–6 months and 7–12 months of follow up.

Conclusion

Exercise-based rehabilitation reduces the risk of recurrent ankle sprain compared to usual care, but there is insufficient data to determine the optimal content of exercise-based interventions. Training volume varied considerably across studies but did not affect the odds of sustaining a re-injury. Effects on patient-reported outcomes and clinical outcomes are equivocal. Future research should compare different exercise contents, training volumes and intensities after ankle sprain.

Anterior ankle impingment syndrome is less frequent, but associated with a longer absence and higher re-injury rate compared to posterior syndrome: a prospective cohort study of 6754 male professional soccer players

PURPOSE

To study the epidemiology and return to play characteristics of anterior and posterior ankle impingement syndromes (AAIS and PAIS) over 18 consecutive seasons in male professional soccer players.

METHODS

Between the 2001-2002 and 2018-2019 seasons, 120 European soccer teams were followed prospectively for various seasons. Time loss injuries and player exposures were recorded individually in 6754 unique players. Injury incidence and burden were reported as the number of injuries and days absence per 1000 h with 95% confidence intervals (CIs). Injury severity was reported as median absence in days with the interquartile range (IQR).

RESULTS

Out of 25,462 reported injuries, 93 (0.4%) were diagnosed as AAIS (38%) or PAIS (62%) in 77 players. AAIS and PAIS were similar regarding injury characteristics except for a greater proportion of AAIS having a gradual onset (69% vs.47%; P = 0.03) and being re-injuries (31% vs. 9%; P = 0.01). Impingement syndromes resulted in an overall incidence of 0.03 injuries (95% CI 0.02-0.03) per 1000 h and an injury burden of 0.4 absence days per 1000 h. PAIS incidence was significantly higher than that for AAIS [0.02 (95% CI 0.002-0.03) vs. 0.01 (95% CI 0.005-0.01) injuries per 1000 h (RR = 1.7). The absence was significantly longer in AAIS than in PAIS [10 (22) vs. 6 (11) days; P = 0.023]. Impingement syndromes that presented with a gradual onset had longer absences in comparison to impingement with an acute onset [8 (22) vs. 5 (11) days; P = 0.014]. Match play was associated with a higher incidence and greater injury burden than training: 0.08 vs. 0.02 injuries per 1000 h (RR 4.7), respectively, and 0.9 vs. 0.3 days absence per 1000 h (RR 2.5).

CONCLUSION

Ankle injuries are frequent in men's professional soccer and ankle impingement is increasingly recognized as a common source of pain, limited range of motion, and potential time loss. In our study, ankle impingement was the cause of time loss in less than 0.5% of all injuries. PAIS was more frequently reported than AAIS, but AAIS was associated with more absence days and a higher re-injury rate than PAIS. The findings in this study can assist the physician in best practice management on ankle impingment syndromes in professional football.

LEVEL OF EVIDENCE

II.

Energy dissipation during single-leg landing from three heights in individuals with and without chronic ankle instability

Inadequate energy dissipation during landing may increase the risk of ankle sprain. Mechanical demands (landing height) in landing tasks may affect the biomechanical differences between individuals with and without chronic ankle instability (CAI). However, energy dissipation strategies during landing from various heights in individuals with CAI are unclear. The purpose of this study was to compare the effect of landing height on lower extremity biomechanics between individuals with and without CAI. Eleven participants in each of the CAI and Control group performed a single-leg landing from three heights (30, 40, and 50 cm). We calculated the contribution of each joint to total energy dissipation at 50-ms intervals during 0-200 ms post-initial contact (IC). Peak joint angles and moments and joint stiffnesses were calculated during 0-200 ms post-IC. Two-way mixed analysis of variance revealed significant group-by-height interactions for hip energy dissipation at 101-150 ms post-IC and peak ankle plantarflexion and hip extension moment. These significant interactions suggested that the effects of landing height on the ankle and hip joints differ between individuals with and without CAI. The effect of mechanical demands on altered landing biomechanics among CAI populations should be considered in biomechanical studies and clinical practice.

Hip Flexibility and Dynamic Balance Ability in Soccer Players with Functional Ankle Instability

The prevention of recurrent ankle sprain and functional ankle instability in soccer players is essential. This study clarified hip joint mobility and dynamic balance ability in soccer players with functional ankle instability. This case–control study included 17 male college soccer players. All participants were assessed using the Cumberland Ankle Instability Tool and were divided into chronic ankle instability (CAI) and non-CAI groups for each of their dominant and nondominant legs. Bilateral passive hip range of motion (ROM) was assessed and the modified Star Excursion Balance Test (mSEBT) was measured for each leg. In the dominant leg, the reach in the posterolateral direction in the CAI group was significantly less than that in the non-CAI group. Hip internal rotation angles in the dominant leg in the CAI group were greater than those in the non-CAI group; however, no significant correlations with the three directions of mSEBT were observed. In the nondominant leg, mSEBT and hip ROMs did not show any significant differences between groups. The dominant leg in soccer players with CAI had poor dynamic balance ability while reaching posterolaterally. However, acquiring hip flexibility may not be necessary to improve the dynamic balance ability. These findings may help develop future research.

Injury epidemiology in professional football in South America compared with Europe

Objective

To describe the injury epidemiology in professional football in South America and compare it with European professional football.

Methods

Data about football exposures and injury occurrences were registered in Six teams participating in Copa Libertadores in 2016. These teams’ exposure and injury data were compared with teams participating in the UEFA Elite Club Injury Study during the 2015/2016 and 2016/2017 seasons.

Results

A total of 271 injuries were reported in the South American cohort representing a training injury incidence of 3.2 (95% CI=2.7 to 3.7) injuries/1000 hours of training exposure and 20.9 (95% CI=17.3 to 25.1) injuries/1000 hours of match exposure. While no differences in muscle injury incidence were observed between South American and European teams, the ligament injury incidence in training among South American teams was significantly higher than European teams (0.6 vs 0.3, RR 1.87, 95% CI 1.21 to 2.87). In addition, a significantly higher proportion of all reported injuries among South American teams than European teams occurred in training.

Conclusions

A larger proportion of injuries occur in training in South American compared with European professional football. Specifically, ligament injuries in training were more frequent among South American teams.

The dominant leg is more likely to get injured in soccer players: systematic review and meta-analysis

In soccer (football), dominant limb kicking produces higher ball velocity and is used with greater frequency than the non-dominant limb. It is unclear whether limb dominance has an effect on injury incidence. The purpose of this systematic review with meta-analysis is to examine the relationship between limb dominance and soccer injuries. Studies were identified from four online databases according to PRISMA guidelines to identify studies of soccer players that reported lower extremity injuries by limb dominance. Relevant studies were assessed for inclusion and retained. Data from retained studies underwent meta-analyses to determine relative risk of dominant versus non-dominant limb injuries using random-effects models. Seventy-four studies were included, with 36 of them eligible for meta-analysis. For prospective lower extremity injury studies, soccer players demonstrated a 1.6 times greater risk of injury to the dominant limb (95% CI [1.3-1.8]). Grouped by injury location, hamstring (RR 1.3 [95% CI 1.1-1.4]) and hip/groin (RR 1.9 [95% CI 1.3-2.7]) injuries were more likely to occur to the dominant limb. Greater risk of injury was present in the dominant limb across playing levels (amateurs RR 2.6 [95% CI 2.1-3.2]; youths RR 1.5 [95% CI 1.26-1.67]; professionals RR 1.3 [95% CI 1.14-1.46]). Both males (RR 1.5 [95% CI 1.33-1.68)] and females (RR 1.5 [95% CI 1.14-1.89]) were more likely to sustain injuries to the dominant limb. Future studies investigating soccer injury should adjust for this confounding factor by using consistent methods for assigning limb dominance and tracking use of the dominant versus non-dominant limb.

Ankle Injuries in Soccer Players: A Narrative Review

Soccer is one of the most popular sport, with many describing it as the "king of sports." In recent years, increased global participation in soccer has led to an inevitable increase in injury rates, especially in the lower extremities. Consequently, there is an increase in the epidemiology of soccer injuries, both in professionals and amateur athletes. The cause of an injury is multifactorial and depends on psychosocial, predisposing, intrinsic, and extrinsic factors. Also, contact with another player and non-contact injuries seem to be the most widespread mechanisms of injuries. The most common injuries recorded in soccer are ankle sprains and hamstrings injuries. More specifically, many studies have shown a correlation between the previous injury in lower extremities, weakness of abductors muscle, and psychosocial factors with the ankle sprain. Additionally, according to study results, injuries in adult men, adolescent men, and women during a match are higher than injuries during training. This narrative review aims to record the epidemiology of ankle injuries, risk factors, and the relationship between circadian rhythm, sleep, and injuries.

[Employees in professional European football: comparison of the personnel structure in sports medicine, sports sciences and physiotherapy between Bundesliga, La Liga, Serie A and Premier League]

INTRODUCTION

Regional and league-specific differences in injury risk and time loss have been observed in professional European football. Besides time of play or different pre-season preparations, possible reasons may also include medical and sport-scientific support. A survey of what UEFA deems to be the best four football clubs has therefore been conducted to investigate the personnel status in the fields of medicine, physiotherapy, massage, sports science and athletic and "strength and conditioning" coaching in order to compare the Erste Bundesliga with the first leagues of the other countries.

METHODS

The study is based on a survey of all 78 teams in the highest football leagues of Germany (Bundesliga), Spain (La Liga), Italy (Serie A) and England (Premier League). The teams were contacted directly and a questionnaire concerning their personnel deployment in the different fields was handed out.

RESULTS

The Bundesliga was found to have a significantly lower total number of employees compared with the other European leagues (6.9 vs. 11.02; p < 0.0001). The number of physicians in the Bundesliga is significantly higher (2.2 vs. 1.76; p = 0.0259), but the number of physicians dedicating more than 80 % of their total medical practice to the team was significantly lower in the Bundesliga (0.2 vs. 1.45; < 0.0001). In the group of physiotherapists (1.8 vs. 3.6; p < 0.001), massage therapists (2.1 vs. 2.69; p = 0.0094), sports scientists (0.3 vs. 1.12; p < 0.0001) and athletic and "strength and conditioning" coaches (0.5 vs. 1.83; p < 0.0001), there were also significant differences between the staff structure in the Bundesliga compared with the grouped results of the other leagues.

CONCLUSION

The personnel structure and the personnel employment in the Bundesliga in sports medicine and sports sciences differs significantly from La Liga, Serie A and the Premier League with the latter three leagues having more personnel and the personnel having closer ties to their teams. Further investigation is necessary to find out if this may be a reason for the differences in injury rates observed between these leagues. A special focus should be placed on country-specific differences in the professions including education and scope of work.

The Temporal Pattern of Recovery in Directional Dynamic Stability Post Football-Specific Fatigue

BACKGROUND

Rising injury rates within football require further understanding of the etiological risk factors associated with lower-limb injury.

AIM

To examine the temporal pattern of recovery of directional dynamic stability measures post football-specific fatigue.

METHODS

Eighteen male elite footballers completed baseline assessments of directional dynamic stability measures (Overall Stability Index, anterior-posterior stability [A-P], medial-lateral stability [M-L] on level 1 of the Biodex Stability System). Post Soccer-Specific Aerobic Field Test90 measures were repeated immediately, +24 hours, +48 hours, and +72 hours. The main effects for the recovery time and direction of stability were supplemented by regression modeling to describe the temporal pattern of recovery.

RESULTS

Significant main effects for time were identified for all directions of stability (Overall Stability Index, A-P, and M-L) up to +48 hours postexercise (P ≤ .05). The quadratic pattern of temporal recovery highlights a minimum of 37.55 to 38.67 hours and maximum of 75.09 to 77.33 hours. Additionally, a main effect for direction of stability was observed, with significant differences identified between A-P and M-L stability at all time points (P ≤ .001).

CONCLUSIONS

Reductions in directional dynamic stability +48 hours postfatigue highlight implications for training design, recovery strategies, and injury management for performance practitioners. Interestingly, A-P stability has been highlighted as being significantly reduced compared with M-L stability at all time points, regardless of the fatigue exposure. Practitioners should consider the reduction of stability in this plane in relation to common mechanisms of injury in the knee to inform injury-risk-reduction strategies.

Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021

This revised clinical practice guideline (CPG) addresses the distinct but related lower extremity impairments of those with a first-time lateral ankle sprain (LAS) and those with chronic ankle instability (CAI). Depending on many factors, impairments may continue following injury. While most individuals experience resolution of symptoms, complaints of instability may continue and are defined as CAI. The aims of the revision were to provide a concise summary of the contemporary evidence since publication of the original guideline and to develop new recommendations or revise previously published recommendations to support evidence-based practice. J Orthop Sports Phys Ther 2021;51(4):CPG1-CPG80. doi:10.2519/jospt.2021.0302.

Injury rates decreased in men's professional football: an 18-year prospective cohort study of almost 12 000 injuries sustained during 1.8 million hours of play

BACKGROUND

The UEFA Elite Club Injury Study is the largest and longest running injury surveillance programme in football.

OBJECTIVE

To analyse the 18-season time trends in injury rates among male professional football players.

METHODS

3302 players comprising 49 teams (19 countries) were followed from 2000-2001 through 2018-2019. Team medical staff recorded individual player exposure and time-loss injuries.

RESULTS

A total of 11 820 time-loss injuries were recorded during 1 784 281 hours of exposure. Injury incidence fell gradually during the 18-year study period, 3% per season for both training injuries (95% CI 1% to 4% decrease, p=0.002) and match injuries (95% CI 2% to 3% decrease, p<0.001). Ligament injury incidence decreased 5% per season during training (95% CI 3% to 7% decrease, p<0.001) and 4% per season during match play (95% CI 3% to 6% decrease, p<0.001), while the rate of muscle injuries remained constant. The incidence of reinjuries decreased by 5% per season during both training (95% CI 2% to 8% decrease, p=0.001) and matches (95% CI 3% to 7% decrease, p<0.001). Squad availability increased by 0.7% per season for training sessions (95% CI 0.5% to 0.8% increase, p<0.001) and 0.2% per season for matches (95% CI 0.1% to 0.3% increase, p=0.001).

CONCLUSIONS

Over 18 years: (1) injury incidence decreased in training and matches, (2) reinjury rates decreased, and (3) player availability for training and match play increased.

Injury Profile in Women's Football: A Systematic Review and Meta-Analysis

BACKGROUND

Football is the most popular sport among women; however, little is known about the injury profile in this population. This information would help design tailored injury risk mitigation strategies that may make football safer for women.

OBJECTIVE

The aim of this study was to perform a systematic review and meta-analysis of epidemiological data of injuries in women´s football.

METHODS

A systematic review following PRISMA guidelines was performed up to January 2020 in PubMed, Web of Science, Sportdiscus and the Cochrane Library databases. Twenty-two studies reporting the incidence of injuries in women football were analysed. Two reviewers independently extracted data (intraclass correlation coefficient [ICC] for inter-reviewer reliability = 0.87) and assessed study quality using the STROBE statement, GRADE approach, Newcastle Ottawa Scale and Downs and Black assessment tools. Studies were combined in pooled analyses (injury incidence and injury proportion) using a Poisson random effects regression model.

RESULTS

The overall incidence of injuries in female football players was 6.1 injuries/1000 h of exposure. Match injury incidence (19.2 injuries/1000 h of exposure) was almost six times higher than training injury incidence rate (3.5 injuries/1000 h of exposure). Lower extremity injuries had the highest incidence rates (4.8 injuries/1000 h of exposure). The most common types of injuries were muscle/tendon (1.8 injuries/1000 h of exposure) and joint (non-bone) and ligament (1.5 injuries/1000 h of exposure), which were frequently associated with traumatic incidents. Slight/minimal injuries (1-3 days of time loss) were the most common. The incidence rate of injuries during matches in the top five world ranking leagues was higher than the rest of the leagues (19.3 vs 10.7 injuries/1000 h of exposure, respectively). The weighted injury proportion was 1.1 (95% confidence interval = 0.6-1.7) whereby on average players sustained more than one injury per season.

CONCLUSIONS

Female football players are exposed to a substantial risk of sustaining injuries, especially during matches that require the highest level of performance. To markedly reduce overall injury burden, efforts should focus on introducing and evaluating preventative measures that target match specific dynamics to make football players more capable of responding to the challenges that they have to deal with during match play.

REGISTRATION

This systematic review was registered in the PROSPERO international prospective register of systematic reviews (ID = CRD42019118152).

Injury and illness epidemiology in professional Asian football: lower general incidence and burden but higher ACL and hamstring injury burden compared with Europe

BACKGROUND

While football injury and illness epidemiology surveillance at professional club level in Europe is available, epidemiological data from other continents are lacking.

PURPOSE

Investigating injury and illness epidemiology in professional Asian football.

STUDY DESIGN

Descriptive prospective study.

METHODS

Professional teams from the Asian Football Confederation (AFC) league were followed prospectively for three consecutive AFC seasons (2017 through 2019, 13 teams per season, 322 team months). Time-loss injuries and illnesses in addition to individual match and training exposure were recorded using standardised digital tools in accordance with international consensus procedures.

RESULTS

In total, 232 665 hours of exposure (88.6% training and 11.4% matches) and 1159 injuries were recorded; 496 (42.8%) occurred during matches, 610 (52.6%) during training; 32 (2.8%) were reported as 'not applicable' and for 21 injuries (1.8%) information was missing. Injury incidence was significantly greater during match play (19.2±8.6 injuries per 1000 hours) than training (2.8±1.4, p<0.0001), resulting in a low overall incidence of 5.1±2.2.The injury burden for match injuries was greater than from training injuries (456±336 days per 1000 hours vs 54±34 days, p<0.0001). The two specific injuries causing the greatest burden were complete ACL ruptures (0.14 injuries (95% CI 0.9 to 0.19) and 29.8 days lost (29.1 to 30.5) per 1000 hours) and hamstring strains (0.86 injuries (0.74 to 0.99) and 17.5 days (17.0 to 18.1) lost per 1000 hours).Reinjuries constituted 9.9% of all injuries. Index injuries caused 22.6±40.8 days of absence compared with 25.1±39 for reinjuries (p=0.62). The 175 illnesses recorded resulted in 1.4±2.9 days of time loss per team per month.

CONCLUSION

Professional Asian football is characterised by an overall injury incidence similar to that reported from Europe, but with a high rate of ACL ruptures and hamstring injury, warranting further investigations.

Peroneal reaction time delayed but dynamic single-legged stability retained in collegiate footballers during a simulated prolonged football protocol

Delayed peroneal reaction time and impaired single-legged dynamic stability were risk factors of lateral ankle sprain (LAS), yet no study explored the change of them during a football match. The aim is to explore the change of peroneal reaction time and single-legged dynamic stability during a football simulation protocol. Twelve collegiate football players voluntarily completed a 105-min football match simulation protocol in which peroneal reaction time, root-mean-square of mediolateral ground reaction force in first 0.4 s (RMS ML 0.4), and the mean mediolateral ground reaction force in the late stage (late dynamic MLGRF), were measured for both legs at 15-min intervals during the protocol. Peroneal reaction time was tested using an electromyography (EMG) system. The ground reaction force variables were measured from GRF data after a single-legged drop-jump landing. Repeated measures one-way MANOVA was conducted to evaluate variables over time and leg dominance. Statistical significance was set at p < 0.05 level. Peroneal reaction time significantly increased for both legs at 45 minutes and after 60 minutes. RMS ML 0.4 of both legs and late dynamic MLGRF for dominant leg remained unchanged throughout the protocol and late dynamic MLGRF for non-dominant leg significantly reduced at the 90th minute.

Utility of Kinetic and Kinematic Jumping and Landing Variables as Predictors of Injury Risk: A Systematic Review

Purpose

Jump-landing assessments provide a means to quantify an individual’s ability to attenuate ground reaction forces, generate lower limb explosive power and maintain joint alignment. In order to identify risk factors that can be targeted through appropriate training interventions, it is necessary to establish which (scalar) objective kinetic, kinematic, and performance measures are most associated with lower-extremity injury.

Methods

Online searches of MEDLINE, SCOPUS, EBSCOHost, SPORTDiscus and PubMed databases were completed for all articles published before March 2020 in accordance with PRISMA guidelines.

Results

40 articles investigating nine jump-landing assessments were included in this review. The 79% of studies using drop jump (n = 14) observed an association with future injury, while only 8% of countermovement jump studies (n = 13) observed an association with injury risk. The 57% of studies using unilateral assessments found associations with risk of injury (n = 14). Studies using performance measures (jump height/distance) as outcome measure were only associated with injury risk in 30% of cases. However, those using kinetic and/or kinematic analyses (knee abduction moment, knee valgus angle, knee separation distance, peak ground reaction force) found associations with injury in 89% of studies.

Conclusion

The landing element of jump-landing assessments appears to be superior for identifying individuals at greater risk of injury; likely due to a closer representation of the injury mechanism. Consequently, jump-landing assessments that involve attenuation of impact forces such as the drop jump appear most suited for this purpose but should involve assessment of frontal plane knee motion and ground reaction forces.

Epidemiology of High Ankle Sprains: A Systematic Review

Syndesmotic sprains or high ankle sprains are reported to be associated with increasing morbidity and time loss. The aim of this study was to critically appraise literature on epidemiology of syndesmotic sprains through systematic review of published literatures. A systematic review was conducted online for literature published in English using PubMed and Google Scholar, as per PRISMA guidelines up to April 30, 2019. Predefined eligibility criteria were applied, and the data thus compiled were analyzed. A total of 26 studies were found to be eligible, of which three-fourths involved sporting population. Considerable inconsistency in assessment procedure reporting, injury and injury severity definition with variable unit measures used to describe incidence or injury rate was observed. Meta-analysis and intra- and intersports comparison could not be performed owing to the study heterogeneity and methodological variability. There is a need for standardization in future research, specifically with regard to injury assessment and reporting, demanding heightened awareness and improved diagnostic modalities, as injury epidemiology is integral to the overall injury-prevention conundrum.Levels of Evidence: Systematic review, Level III.

Ankle osteoarthritis and its association with severe ankle injuries, ankle surgeries and health-related quality of life in recently retired professional male football and rugby players: a cross-sectional observational study

OBJECTIVES

To determine (1) the prevalence of ankle osteoarthritis (OA) among former professional football and rugby players, (2) assess the association between ankle injuries or ankle surgeries with ankle OA, and (3) compare the mental and physical quality of life (QoL) between former professional football and rugby players with and without OA.

METHODS

We conducted a questionnaire-based observational study with a cross-sectional design. Former professional football and rugby players were recruited by the Football Players Worldwide and the International Rugby Players. Information concerning ankle OA, sustained ankle injuries and ankle surgeries was gathered (medical record or most recent medical professional). Health-related QoL was assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) physical and mental health scores.

RESULTS

Overall, 553 former professional football (n=401) and rugby (n=152) players were enrolled in the study (response rate of 56%). Ankle OA prevalence among former professional football and rugby players was 9.2% and 4.6%, respectively. Football players were more likely to suffer from ankle OA following every ankle injury and/or surgery. Football and rugby players with ankle OA had similar PROMIS physical and mental health scores to the norm for the general population.

CONCLUSION

Former professional football and rugby players had higher ankle OA prevalence than the general population (3.4%). Football players are more likely to suffer from ankle OA following every ankle injury and/or surgery. No clinically relevant difference was seen for physical or mental health-related QoL among football and rugby players. Preventive measures for ankle injuries are recommended.

Return to Play After a Lateral Ligament Ankle Sprain

Purpose of Review

The purpose of this review is to describe the current evidence on the most common sports-related ankle injuries. Joint anatomy, epidemiology, clinical findings, diagnostic approach, and treatment are presented with a specific focus on the available evidence towards return to play.

Recent Findings

Recent findings show that ankle sprain is the most common injury in the world of sports. Bony fractures, cartilage defects, and syndesmotic lesions are frequently seen in association with the more severe type of ankle sprains.

Summary

In summary, the majority of the athletes’ ankle sprains are managed conservatively with excellent outcomes and full return to their pre-injury level of play. However, it is essential to differentiate the single ligament sprain from a more complex injury to the ankle joint. The evidence-based treatment and rehabilitation programmes are associated with a better prognosis and a faster time to return to sport participation.

The Effect of Proprioceptive Training on Directional Dynamic Stabilization

OBJECTIVES

Significant loss of playing time and the impact of treatment costs due to lower limb injury in football demonstrates a need for improved protocols for injury risk reduction. The aim of the present study is to assess the effect of a proprioceptive training program on the lower limb dynamic stability of elite footballers.

METHODS

A total of 16 elite premier league footballers were randomly allocated by matched pair design to a 8-week proprioception training group (group A, n = 8) or nontraining group (group B, n = 8), to determine the effect of this training over a 16-week period. Group A completed 8 weeks of bilateral proprioceptive training, 5 times per week for 10 minutes. The Biodex Stability System measures of overall stability index, anterior-posterior (A-P), and medial-lateral stability (M-L) at levels 8-6-4-1 were taken for both groups at baseline, 4, 8, and 16 weeks. Main effects of time, level of stability, and direction of stability were determined, with comparisons of effect made between the 2 groups.

RESULTS

The training group displayed significant differences for multidirectional stability at week 8 (P ≤ .05). The A-P stability within the training group displayed significant differences between baseline measures and 16 weeks (P > .05), with significant increases in scores displayed for M-L and A-P stability between weeks 8 and 16 (P ≤ .05), representing a detraining effect. No significant differences were detected at any time point for the nontraining group (P > .05).

CONCLUSIONS

Proprioceptive training over 8 weeks has a positive effect on all directions of stability. Greater declines in A-P stability were evident at 16 weeks when compared with M-L and overall stability index. Consideration must be given to the increased stability scores presented pretesting for A-P when compared with M-L. Findings of this work present implications for training design.

Epidemiology of hip and groin injuries in Swedish male first football league

PURPOSE

This study aimed to investigate the incidence, pattern, and burden of hip/groin injuries in Swedish professional male football players over five consecutive seasons.

METHODS

Injury history from 16 football teams in the Swedish male first football league was evaluated during five consecutive seasons. The team's medical staff recorded team exposure and time-loss injuries prospectively between 2012 and 2016.

RESULTS

In total, 467 time-loss injuries located in the hip/groin area were recorded among 1,687 professional male football players, with an overall incidence and burden of 0.82/1,000 h and 15.6/1,000 h, respectively. There appeared to be an increased risk of hip/groin injuries during the last two seasons (2015-2016); however, the difference was not statistically significant (n.s). Recurrent injury rate was relatively low (14%), and overuse injuries accounted for the majority of injuries and absence days. Muscle injuries were the main injury type, while kicking and sprinting/running were the primary causes of injury. Goalkeepers had the lowest percentage of injuries and absence days.

CONCLUSION

Hip/groin injuries are a substantial problem in football, but does not seem to be an increasing phenomenon in the Swedish male first football league. Index and overuse injuries accounted for the majority of injuries and absence days. Thus, the focus should be on preventing hip/groin injuries to lower the injury rate. These new findings should be taken into consideration when designing and implementing preventive training interventions.

LEVEL OF EVIDENCE

II.