Soccer: Save the knees

Today I learned that two players on one soccer team suffered ACL (knee ligament) tears in one day. The athletes will be having surgery and miss the fall season. This did not occur during intramural or middle-aged pick-up soccer, but in an NCAA D1 womens soccer team. Two major knee injuries in one day seems stunning. But according to the data, this truly is no surprise.

I have nothing against this university. In fact, I’m well aware that this particular university happens to be at forefront of teaching and research regarding musculoskeletal injuries. I understand that injuries in sports are inevitable. Accidents occur despite the most well laid out precautions and planning.

But I have some observations to offer. I’ve seen a fair share of collegiate soccer players over the years, in the clinic and around the house. Not hundreds of them, but plenty enough to notice patterns.

Fact#1: Soccer is a game of repeated cutting, sprinting, accelerating various directions, and even jumping.

Fact #2: Since the knee joint is the largest lever in the body, situated between the two longest body segments, the brunt of high stress tends to fall there. In soccer players, knees and ankles are by far the most common injured part of the body.

How are these athletes preparing for the demands of fall soccer practices and the upcoming season? They are jogging. Jogging long and slow. Jogging somewhat fast (yeah, I cannot run a 5-minute mile either). They are doing tedious interval sprints, mostly in a straight line. They are fearful of failing the timed mile, two mile, or other gut-busting tests of endurance and grit.

They choose not to do much in terms of plyometric or resistance training due to lacking the time, know-how, or means to build up gradually, and high intensity plyometrics and weight training leaves them too sore and tired for the running protocol. I don’t blame them. People are not machines. Who has the energy for resistance training, cutting, jumping, and quality-of-movement work, when they need to drop a minute off their timed mile?

For more than a few years, we have known many of the risk factors to look for, and specific interventions that have been proven to lessen the risk of ACL tears. We know the demands of a typical soccer match, such as those found here and here. 726 turns during a single match, and still we have athletes focused on jogging. There’s a better way to do summer!

5 KEYS FOR PRESEASON SOCCER PREP

• Sprint and change-of-direction/acceleration training, beginning with moderate speeds focusing on movement QUALITY, and gradually increasing in speed, impact, and repetition.
• Plyometric training, with jumps, hops, striders, tuck jumps, etc, focusing first on movement QUALITY and gradually building in speed, impact, and repetition.
• -Intelligent- application of strength training, building a base of hip mobility, leg and core strength, with gradual transition to fairly heavy/low repetition total body exercises. We’re not talking about nauseating cross training with weights. Neither do we speak of the typical leg curls and power cleans, which are completed on no legs or two legs. Most high level athletic movements (and virtually every non-contact ACL tear) takes place with bodyweight on one leg. Most soccer players will drastically improve performance and decrease risk of injury when they focus on strength and power in single leg movements in multiple directions.
• Proprioception training. The literature states that not all athletes are lacking in their ability to feel and control body movements. But the ones who are lacking in this regard stand to benefit greatly from a handful of activities that fine-tune balance and body awareness.
• Movement Screen (Assessment) While not being predictive of who will suffer injury, this is invaluable for determining exactly what the athlete should be doing and where they can enter in to the continuum of strength training and conditioning.

Truly, it’s not difficult to include these in a weekly and monthly training regimen. Keep it simple and abbreviated. Quality trumps quantity, so resist the temptation to simply add these components to the status quo running protocol. An athlete’s time and ability to adapt and recover is finite, so something has to go.

I’m still relatively new to soccer culture. But I would love to see coaches adjust their preseason conditioning tests to reflect lower body power, and short bursts of multidirectional movement. A grueling test of endurance is absolutely called for in the preseason to use as a gauge of work ethic and grit. But this should not be the emphasis. Do not let the demand for running endurance rob the entire team of time and energy better spent elsewhere.

And the few high level players who show up to fall practice “out of shape?” Let them run distance with a ball, after practice. That’s the time to tack a mile or three of endurance work on to the athletes who need it. It should only take 15 minutes or so ; ).

Here are a few of the risk factors for ACL tear

1. dry weather and surface
2. artificial surface instead of natural grass
3. generalized and specific knee joint laxity
4. small and narrow intercondylar notch width of the femur (ratio of notch width to the diameter and cross sectional area of the ACL)
5. pre-ovulatory phase of menstrual cycle in females not using oral contraceptives
6. decreased relative (to quadriceps) hamstring strength and recruitment
7. muscular fatigue by altering neuromuscular control
8. decreased core strength
9. decreased proprioception
10. low trunk, hip, and knee flexion angles, and high dorsiflexion of the ankle when performing sport tasks
11. lateral trunk displacement, hip adduction (collapse), increased knee abduction moments (dynamic knee valgus
12. increased hip internal rotation and tibial (lower leg) external rotation with or without foot pronation