The American Journal of Orthopedics

Patient satisfaction is related to both the outcomes of care and the process of care. As first described by Donabedian,¹⁰patients may be satisfied with the successful outcome of their care, but dissatisfied with how they received their care. The process of care is complex and considers many aspects of healthcare delivery, including time, cost, healthcare provider interactions, and burdens faced. While patient satisfaction with outcomes and process of care are heavily related, they should be regarded separately. It is essential that providers understand what variables are important to patients with regards to how they experience healthcare and choose their provider, especially surrounding elective procedures such as hip and knee arthroplasty.^11,12

Within orthopedic surgery, patient satisfaction scores are beginning to be incorporated as part of the standard-of-care quality metrics obtained along with patient-reported outcome measures (PROMs) at defined time points postoperatively. Furthermore, PROMs and patient satisfaction data are becoming an increasingly important component of medical decision-making.^13-16 Several authors have reported that increased patient satisfaction is correlated with increased compliance, improved treatment outcomes across numerous medical settings, including orthopedics, decreased risk of litigation, and higher patient ratings of the quality of care.^17,18 Various factors, including meeting of expectations, staff politeness, the communication skills of the surgeon, and waiting times, have been suggested to influence eventual patient satisfaction within the surgical literature.^19-21 However, within orthopedic surgery there is a paucity of investigations evaluating how patients determine preferences and satisfaction with the process of care.

The purpose of this study is to determine what preferences, if any, patients have when selecting their physician and how they experience care in an outpatient orthopedic setting. The authors hypothesize that the majority of patients find their physicians through online rating sites or recommendations from family and friends. The authors believe that patients expect to be seen in <30 minutes and will be unsatisfied overall with the amount of time that they spend with their physician.

Continue to: METHODS...

METHODS

The senior author (BRL) and a research team created a 15-question survey to evaluate patient preferences regarding the demographic characteristics (eg, age, gender, ethnicity) of their physician, wait times in a waiting room, time spent with the physician, care received from physician extenders (eg, nurse practitioners, physician assistants), and how they learned of their physician (Appendix). An a priori power analysis was conducted to determine that approximately 200 patients were needed for inclusion.^11,22 Following Institutional Review Board approval (ORA 15051104), the survey was administered to 212 patients in a single-surgeon, adult reconstruction clinic. The survey was digitally administered on a touch-screen tablet using an electronic independent third party survey center (SurveyMonkey Inc) devoid of any identifying data. The survey was offered to all patients >21 years of age who were English-speaking and in the common area as patients waiting to be seen, from June 2015 to March 2016. A research assistant approached patients in the waiting room and asked if they would like to participate in a short survey regarding what factors influence the patient-physician relationship from the patient’s perspective.

Appendix 1

1. Do you wish to partake in this 3-minute survey?
   1.  
   2.  

1. Have you had a prior knee or hip replacement?
   1.  
   2.  

1. What is your age?
   1. 30-40 years
   2. 40-50 years
   3. 50-60 years
   4. 60-70 years
   5. 70-80 years
   6. 80+ years

1. What is your gender?
   1.  
   2.  

1. Which of the following best represents your racial or ethnic heritage?
   1. African American
   2.  
   3.  
   4.  
   5.  

1. How much time would you like the doctor to spend talking to you on a routine visit?
   1. 0-5 minutes
   2. 5-10 minutes
   3. 10-15 minutes
   4. 15-20 minutes
   5. 20-30 minutes
   6. >30 minutes

1. How long is too long to wait to see the doctor?
   1. 10 minutes
   2. 20 minutes
   3. 30 minutes
   4. 40 minutes
   5. 50 minutes
   6. An hour or more

1. If you were to only see a physician’s assistant or nurse practitioner at your follow-up visit and not the doctor, would you feel like you were getting below average care?
   1.  
   2.  

1. Overall I am satisfied with the time the doctor spends with me.
   1.  
   2.  

1. If you were to need a major surgery, would you want the physician to tell you what he or she would do if they were in your shoes?
   1.  
   2.  

1. Would you prefer your doctor to be the same race/ethnicity as you?
   1. No
   2.  
   3. No Preference

1. Would you feel more comfortable with a male as opposed to a female orthopedic surgeon?
   1.  
   2.  

1. Would you feel more comfortable with a female as opposed to a male orthopedic surgeon?
   1.  
   2.  

1. What age would you like your physician to be?
   1. 25-35 years old
   2. 35-45 years old
   3. 45-55 years old
   4. 55-65 years old
   5. 65 years and older
   6. No preference

1. How do you usually find your physician?
   1.  
   2. Friends’ recommendations
   3. Healthcare provider’s recommendations
   4. Insurance plans
   5. Online research/ratings
   6. Other

Descriptive statistics were used to analyze subject demographics and survey responses. Chi-square analyses and multinomial logistic regressions were utilized to compare responses. All statistical analyses were conducted using SPSS version 24.0 software (SPSS Inc). Statistical significance was set at P < 0.05.

RESULTS

Of the 212 patients who were invited to participate, 196 patients (92.4%) agreed and completed the survey. Demographic and surgical history information can be found in Table 1. The majority of patients were female (62%) and above the age of 50 years (92.4%). Almost half (48.5%) of patients had a prior hip or knee replacement.

Table 1. Survey Respondent Demographics

When asked how long is too long to wait to see the doctor, 30 minutes (39.8%) was most commonly selected, followed by 40 minutes (24.5%) (Figure 1). When asked how much time patients would like the doctor to spend with them during an office visit, the majority (68.9%) selected either 10 to 15 minutes (41.3%) or 15 to 20 minutes (27.6%) (Figure 2). The majority of patients (92.3%) were satisfied with the amount of time the doctor spent with them. In addition, 94.9% of respondents would want their doctor to tell them what they would do if they were in the patient’s shoes when making decisions regarding their medical care (Table 2). Less than half of respondents (41.8%) believe that seeing a physician extender (eg, nurse practitioner or physician assistant) at a postoperative visit would result in a lower quality of care (Table 2).

Table 2. Responses to Survey Questions

When asked if patients preferred a doctor of the same race/ethnicity, the vast majority (83.7%) had no preference (Table 2). There was no significant difference found between male and female respondents when asked if they would feel more comfortable with a male as opposed to a female orthopedic surgeon (P = .118) and vice versa (P = .604) (Table 3). Most patients preferred a physician between the ages of 45 and 55 years (39.3%), followed by 35 and 45 years (23.0%); however, this preference was not statistically significant (Table 4). Older patients were more likely to prefer younger physicians (odds ratio, 4.612 for 25-35 years of age; odds ratio, 1.328 for 35-45 years of age). Only 12.2% of patients reported online research/rating sites as the main resource utilized when selecting their physician (Figure 3). The majority (68.4%) reported that recommendations from either friends (35.2%) or healthcare providers (33.2%) were the main avenues through which they found their physicians.

Table 3. Overall Responses to Questions Regarding Male and Female Orthopedic Surgeons^a

^aResponses were broken down by gender and compared utilizing a 2 x 2 chi-square analysis to test for significant differences in respondents’ gender preferences for their orthopedic surgeon.

Table 4. Patient Preferences Regarding Physician Age

^aNo preference was used as the reference category for the answer choices, while the age bracket “>80 years” was used as the reference for the age of respondent variable.

Continue to: DISCUSSION... 

DISCUSSION

The results of this study demonstrate that patients have several expectations and preferences with regards to the care they receive from physicians in the office. Patients prefer to wait <30 minutes before seeing their provider and desire only 10 to 20 minutes with their doctor. Patients do not have specific preferences with regards to the gender or ethnicity of their physician but would prefer a physician in the middle of their career, aged 45 to 55 years. Ultimately, patients do believe that seeing a physician at a postoperative visit is important, as just under half of patients thought that seeing a physician extender alone at a postoperative visit resulted in a lower quality of care.

While these results were obtained in a population specifically seeking the care of an orthopedic adult reconstruction surgeon, the results demonstrate that patients do not necessarily desire an unreasonable amount of time with their doctor. Patients simply want to be seen in a timely fashion and receive the full undivided attention of their doctor for approximately 20 minutes. Similarly, Patterson and colleagues²² found, in their series of 182 patients who presented to an orthopedic surgeon, that there was a significant correlation between time spent with the surgeon and overall patient satisfaction. Interestingly, the authors reported that patient satisfaction was not correlated with education level, sex, marital status, whether the patients were evaluated by a resident physician before seeing the attending surgeon, self-reported mental status, tobacco usage, the type of clinic visit, or the waiting time to see the surgeon (average, about 40 minutes for this cohort).²² Similarly, Teunis and colleagues²³ reported an average 32-minute wait time in 81 patients presenting for care at an orthopedic hand clinic and demonstrated that a longer wait time was associated with decreased patient satisfaction. These results corroborate the findings of this study that a short wait time is important to patients when evaluating the process of care. Additionally, patients do not have unreasonable expectations with regards to the amount of time they would like to spend with the physician. A physician who has a clinic for 9 hours a day would thus be able to see 54 patients and still spend at least 10 minutes with each patient. The quality of the physician-patient interaction is likely more important than the actual amount of time spent; however, based on this study, patients do have certain expectations about how much time physicians should spend with them.

There were no significant sex, age, or ethnicity preferences in our specific patient cohort. However, a sizable percentage of respondents, 41.8%, believed that they were receiving inferior care if they only saw a physician extender at a routine follow-up visit. Many orthopedic surgeons rely on the care provided by physician extenders to enable them to see additional patients. Physician extenders are well trained to provide high-quality care, including at routine postoperative visits. The results of this study, that many patients believe physician extenders provide lower-quality care, may be a result of inadequate patient education regarding the extensive training and education physician extenders undergo. Physician extenders are qualified, licensed healthcare professionals who are playing increasingly important roles within orthopedics and medicine as a whole. As the demand for orthopedic surgeons to see more patients increases, so does the role of physician extenders. Future research is warranted into educating the public regarding the importance of these healthcare providers and the adequacy of their training.

While many practices now routinely obtain patient satisfaction scores, another modality through which patients can express their satisfaction and experiences with healthcare providers is through online internet physician rating sites (IPRS). These sites have exploded in number and popularity in recent years and, according to some studies, have a very real effect on provider selection.²⁴ Interestingly, a low percentage of patients in this study utilized IPRS reviews to find their doctors. In a recent prospective survey study of 1000 consecutive patients presenting for care at the Mayo Clinic, Burkle and Keegan²⁴ reported that 27% of patients would choose not to see a physician based on a negative IPRS review. Interestingly, only 1.0% of patients reported finding their doctor through advertising. Numerous authors have recently addressed advertising in orthopedic surgery, specifically direct-to-consumer marking, including the influence of physician self-promotion on patients.^25,26 Specifically, Halawi and Barsoum²⁶ discussed how direct-to-consumer marketing is commonly disseminated to the public through television and print advertisements, which are modalities more commonly utilized by older generations. However, many advertising agencies are moving toward internet-based advertising, especially through orthopedic group and individual surgeon websites for self-promoting advertisement, as approximately 75% of Americans use the internet for health-related information.^25,27 The fact that many patients in this study did not utilize IPRS reviews or advertising (much of which is electronic) may be a result of the older, less internet-centric demographic that is often seen in an adult reconstruction clinic. Future research is warranted to determine what demographic of patients value IPRS reviews and how those reviews influence physician selection and the patient experience. 

There are several limitations to this study. First, the majority of the surveyed population was Caucasian, and our results may not be equally reflective of diverse ethnic backgrounds. Second, the cohort size, while based on previous studies conducted in a similar fashion, may be underpowered to detect significant differences for 1 or more of these questions. In addition, having a question regarding the patient’s medical background or experiences may have provided further insight as to why patients selected the answers that they did. Furthermore, questions regarding the patient’s education level, religious background, and income brackets may have provided further context in which to evaluate their responses. These questions were omitted in an effort to keep the questionnaire at a length that would maximize enrollment and prevent survey fatigue. Future research is warranted to determine what patient-specific, injury/symptom-specific, and treatment-specific variables influence the subjective patient experience.

CONCLUSION

The vast majority of patients desire only 10 to 20 minutes with their doctor and are highly satisfied with the amount of time their surgeon spends with them. Patients reported no significant gender- or ethnicity-based preferences for their doctor. The majority of patients believe that a wait time exceeding 30 minutes is too long. A greater effort needs to be made to educate patients and the public about the significant and effective roles nurse practitioners and physician assistants can play within the healthcare system. While this cohort did not report notable utilization of IPRS reviews, it remains essential to understand what factors influence patients’ subjective experiences with their providers to ensure that patients achieve their desired outcomes, and report as such on these websites as they continue to gain popularity. Diminishing clinic wait times and understanding patient preferences may lead to a greater percentage of “satisfied” patients. While the majority of focus has been and will likely continue to be on improving patients’ satisfaction with their outcomes, more work needs to be done focusing specifically on the process through which outcomes are achieved.

Patient satisfaction is related to both the outcomes of care and the process of care. As first described by Donabedian,¹⁰patients may be satisfied with the successful outcome of their care, but dissatisfied with how they received their care. The process of care is complex and considers many aspects of healthcare delivery, including time, cost, healthcare provider interactions, and burdens faced. While patient satisfaction with outcomes and process of care are heavily related, they should be regarded separately. It is essential that providers understand what variables are important to patients with regards to how they experience healthcare and choose their provider, especially surrounding elective procedures such as hip and knee arthroplasty.^11,12

Within orthopedic surgery, patient satisfaction scores are beginning to be incorporated as part of the standard-of-care quality metrics obtained along with patient-reported outcome measures (PROMs) at defined time points postoperatively. Furthermore, PROMs and patient satisfaction data are becoming an increasingly important component of medical decision-making.^13-16 Several authors have reported that increased patient satisfaction is correlated with increased compliance, improved treatment outcomes across numerous medical settings, including orthopedics, decreased risk of litigation, and higher patient ratings of the quality of care.^17,18 Various factors, including meeting of expectations, staff politeness, the communication skills of the surgeon, and waiting times, have been suggested to influence eventual patient satisfaction within the surgical literature.^19-21 However, within orthopedic surgery there is a paucity of investigations evaluating how patients determine preferences and satisfaction with the process of care.

The purpose of this study is to determine what preferences, if any, patients have when selecting their physician and how they experience care in an outpatient orthopedic setting. The authors hypothesize that the majority of patients find their physicians through online rating sites or recommendations from family and friends. The authors believe that patients expect to be seen in <30 minutes and will be unsatisfied overall with the amount of time that they spend with their physician.

Continue to: METHODS...

METHODS

The senior author (BRL) and a research team created a 15-question survey to evaluate patient preferences regarding the demographic characteristics (eg, age, gender, ethnicity) of their physician, wait times in a waiting room, time spent with the physician, care received from physician extenders (eg, nurse practitioners, physician assistants), and how they learned of their physician (Appendix). An a priori power analysis was conducted to determine that approximately 200 patients were needed for inclusion.^11,22 Following Institutional Review Board approval (ORA 15051104), the survey was administered to 212 patients in a single-surgeon, adult reconstruction clinic. The survey was digitally administered on a touch-screen tablet using an electronic independent third party survey center (SurveyMonkey Inc) devoid of any identifying data. The survey was offered to all patients >21 years of age who were English-speaking and in the common area as patients waiting to be seen, from June 2015 to March 2016. A research assistant approached patients in the waiting room and asked if they would like to participate in a short survey regarding what factors influence the patient-physician relationship from the patient’s perspective.

Appendix 1

1. Do you wish to partake in this 3-minute survey?
   1.  
   2.  

1. Have you had a prior knee or hip replacement?
   1.  
   2.  

1. What is your age?
   1. 30-40 years
   2. 40-50 years
   3. 50-60 years
   4. 60-70 years
   5. 70-80 years
   6. 80+ years

1. What is your gender?
   1.  
   2.  

1. Which of the following best represents your racial or ethnic heritage?
   1. African American
   2.  
   3.  
   4.  
   5.  

1. How much time would you like the doctor to spend talking to you on a routine visit?
   1. 0-5 minutes
   2. 5-10 minutes
   3. 10-15 minutes
   4. 15-20 minutes
   5. 20-30 minutes
   6. >30 minutes

1. How long is too long to wait to see the doctor?
   1. 10 minutes
   2. 20 minutes
   3. 30 minutes
   4. 40 minutes
   5. 50 minutes
   6. An hour or more

1. If you were to only see a physician’s assistant or nurse practitioner at your follow-up visit and not the doctor, would you feel like you were getting below average care?
   1.  
   2.  

1. Overall I am satisfied with the time the doctor spends with me.
   1.  
   2.  

1. If you were to need a major surgery, would you want the physician to tell you what he or she would do if they were in your shoes?
   1.  
   2.  

1. Would you prefer your doctor to be the same race/ethnicity as you?
   1. No
   2.  
   3. No Preference

1. Would you feel more comfortable with a male as opposed to a female orthopedic surgeon?
   1.  
   2.  

1. Would you feel more comfortable with a female as opposed to a male orthopedic surgeon?
   1.  
   2.  

1. What age would you like your physician to be?
   1. 25-35 years old
   2. 35-45 years old
   3. 45-55 years old
   4. 55-65 years old
   5. 65 years and older
   6. No preference

1. How do you usually find your physician?
   1.  
   2. Friends’ recommendations
   3. Healthcare provider’s recommendations
   4. Insurance plans
   5. Online research/ratings
   6. Other

Descriptive statistics were used to analyze subject demographics and survey responses. Chi-square analyses and multinomial logistic regressions were utilized to compare responses. All statistical analyses were conducted using SPSS version 24.0 software (SPSS Inc). Statistical significance was set at P < 0.05.

RESULTS

Of the 212 patients who were invited to participate, 196 patients (92.4%) agreed and completed the survey. Demographic and surgical history information can be found in Table 1. The majority of patients were female (62%) and above the age of 50 years (92.4%). Almost half (48.5%) of patients had a prior hip or knee replacement.

Table 1. Survey Respondent Demographics

When asked how long is too long to wait to see the doctor, 30 minutes (39.8%) was most commonly selected, followed by 40 minutes (24.5%) (Figure 1). When asked how much time patients would like the doctor to spend with them during an office visit, the majority (68.9%) selected either 10 to 15 minutes (41.3%) or 15 to 20 minutes (27.6%) (Figure 2). The majority of patients (92.3%) were satisfied with the amount of time the doctor spent with them. In addition, 94.9% of respondents would want their doctor to tell them what they would do if they were in the patient’s shoes when making decisions regarding their medical care (Table 2). Less than half of respondents (41.8%) believe that seeing a physician extender (eg, nurse practitioner or physician assistant) at a postoperative visit would result in a lower quality of care (Table 2).

Table 2. Responses to Survey Questions

When asked if patients preferred a doctor of the same race/ethnicity, the vast majority (83.7%) had no preference (Table 2). There was no significant difference found between male and female respondents when asked if they would feel more comfortable with a male as opposed to a female orthopedic surgeon (P = .118) and vice versa (P = .604) (Table 3). Most patients preferred a physician between the ages of 45 and 55 years (39.3%), followed by 35 and 45 years (23.0%); however, this preference was not statistically significant (Table 4). Older patients were more likely to prefer younger physicians (odds ratio, 4.612 for 25-35 years of age; odds ratio, 1.328 for 35-45 years of age). Only 12.2% of patients reported online research/rating sites as the main resource utilized when selecting their physician (Figure 3). The majority (68.4%) reported that recommendations from either friends (35.2%) or healthcare providers (33.2%) were the main avenues through which they found their physicians.

Table 3. Overall Responses to Questions Regarding Male and Female Orthopedic Surgeons^a

^aResponses were broken down by gender and compared utilizing a 2 x 2 chi-square analysis to test for significant differences in respondents’ gender preferences for their orthopedic surgeon.

Table 4. Patient Preferences Regarding Physician Age

^aNo preference was used as the reference category for the answer choices, while the age bracket “>80 years” was used as the reference for the age of respondent variable.

Continue to: DISCUSSION... 

DISCUSSION

The results of this study demonstrate that patients have several expectations and preferences with regards to the care they receive from physicians in the office. Patients prefer to wait <30 minutes before seeing their provider and desire only 10 to 20 minutes with their doctor. Patients do not have specific preferences with regards to the gender or ethnicity of their physician but would prefer a physician in the middle of their career, aged 45 to 55 years. Ultimately, patients do believe that seeing a physician at a postoperative visit is important, as just under half of patients thought that seeing a physician extender alone at a postoperative visit resulted in a lower quality of care.

While these results were obtained in a population specifically seeking the care of an orthopedic adult reconstruction surgeon, the results demonstrate that patients do not necessarily desire an unreasonable amount of time with their doctor. Patients simply want to be seen in a timely fashion and receive the full undivided attention of their doctor for approximately 20 minutes. Similarly, Patterson and colleagues²² found, in their series of 182 patients who presented to an orthopedic surgeon, that there was a significant correlation between time spent with the surgeon and overall patient satisfaction. Interestingly, the authors reported that patient satisfaction was not correlated with education level, sex, marital status, whether the patients were evaluated by a resident physician before seeing the attending surgeon, self-reported mental status, tobacco usage, the type of clinic visit, or the waiting time to see the surgeon (average, about 40 minutes for this cohort).²² Similarly, Teunis and colleagues²³ reported an average 32-minute wait time in 81 patients presenting for care at an orthopedic hand clinic and demonstrated that a longer wait time was associated with decreased patient satisfaction. These results corroborate the findings of this study that a short wait time is important to patients when evaluating the process of care. Additionally, patients do not have unreasonable expectations with regards to the amount of time they would like to spend with the physician. A physician who has a clinic for 9 hours a day would thus be able to see 54 patients and still spend at least 10 minutes with each patient. The quality of the physician-patient interaction is likely more important than the actual amount of time spent; however, based on this study, patients do have certain expectations about how much time physicians should spend with them.

There were no significant sex, age, or ethnicity preferences in our specific patient cohort. However, a sizable percentage of respondents, 41.8%, believed that they were receiving inferior care if they only saw a physician extender at a routine follow-up visit. Many orthopedic surgeons rely on the care provided by physician extenders to enable them to see additional patients. Physician extenders are well trained to provide high-quality care, including at routine postoperative visits. The results of this study, that many patients believe physician extenders provide lower-quality care, may be a result of inadequate patient education regarding the extensive training and education physician extenders undergo. Physician extenders are qualified, licensed healthcare professionals who are playing increasingly important roles within orthopedics and medicine as a whole. As the demand for orthopedic surgeons to see more patients increases, so does the role of physician extenders. Future research is warranted into educating the public regarding the importance of these healthcare providers and the adequacy of their training.

While many practices now routinely obtain patient satisfaction scores, another modality through which patients can express their satisfaction and experiences with healthcare providers is through online internet physician rating sites (IPRS). These sites have exploded in number and popularity in recent years and, according to some studies, have a very real effect on provider selection.²⁴ Interestingly, a low percentage of patients in this study utilized IPRS reviews to find their doctors. In a recent prospective survey study of 1000 consecutive patients presenting for care at the Mayo Clinic, Burkle and Keegan²⁴ reported that 27% of patients would choose not to see a physician based on a negative IPRS review. Interestingly, only 1.0% of patients reported finding their doctor through advertising. Numerous authors have recently addressed advertising in orthopedic surgery, specifically direct-to-consumer marking, including the influence of physician self-promotion on patients.^25,26 Specifically, Halawi and Barsoum²⁶ discussed how direct-to-consumer marketing is commonly disseminated to the public through television and print advertisements, which are modalities more commonly utilized by older generations. However, many advertising agencies are moving toward internet-based advertising, especially through orthopedic group and individual surgeon websites for self-promoting advertisement, as approximately 75% of Americans use the internet for health-related information.^25,27 The fact that many patients in this study did not utilize IPRS reviews or advertising (much of which is electronic) may be a result of the older, less internet-centric demographic that is often seen in an adult reconstruction clinic. Future research is warranted to determine what demographic of patients value IPRS reviews and how those reviews influence physician selection and the patient experience. 

There are several limitations to this study. First, the majority of the surveyed population was Caucasian, and our results may not be equally reflective of diverse ethnic backgrounds. Second, the cohort size, while based on previous studies conducted in a similar fashion, may be underpowered to detect significant differences for 1 or more of these questions. In addition, having a question regarding the patient’s medical background or experiences may have provided further insight as to why patients selected the answers that they did. Furthermore, questions regarding the patient’s education level, religious background, and income brackets may have provided further context in which to evaluate their responses. These questions were omitted in an effort to keep the questionnaire at a length that would maximize enrollment and prevent survey fatigue. Future research is warranted to determine what patient-specific, injury/symptom-specific, and treatment-specific variables influence the subjective patient experience.

CONCLUSION

The vast majority of patients desire only 10 to 20 minutes with their doctor and are highly satisfied with the amount of time their surgeon spends with them. Patients reported no significant gender- or ethnicity-based preferences for their doctor. The majority of patients believe that a wait time exceeding 30 minutes is too long. A greater effort needs to be made to educate patients and the public about the significant and effective roles nurse practitioners and physician assistants can play within the healthcare system. While this cohort did not report notable utilization of IPRS reviews, it remains essential to understand what factors influence patients’ subjective experiences with their providers to ensure that patients achieve their desired outcomes, and report as such on these websites as they continue to gain popularity. Diminishing clinic wait times and understanding patient preferences may lead to a greater percentage of “satisfied” patients. While the majority of focus has been and will likely continue to be on improving patients’ satisfaction with their outcomes, more work needs to be done focusing specifically on the process through which outcomes are achieved.

Patient satisfaction is related to both the outcomes of care and the process of care. As first described by Donabedian,¹⁰patients may be satisfied with the successful outcome of their care, but dissatisfied with how they received their care. The process of care is complex and considers many aspects of healthcare delivery, including time, cost, healthcare provider interactions, and burdens faced. While patient satisfaction with outcomes and process of care are heavily related, they should be regarded separately. It is essential that providers understand what variables are important to patients with regards to how they experience healthcare and choose their provider, especially surrounding elective procedures such as hip and knee arthroplasty.^11,12

Within orthopedic surgery, patient satisfaction scores are beginning to be incorporated as part of the standard-of-care quality metrics obtained along with patient-reported outcome measures (PROMs) at defined time points postoperatively. Furthermore, PROMs and patient satisfaction data are becoming an increasingly important component of medical decision-making.^13-16 Several authors have reported that increased patient satisfaction is correlated with increased compliance, improved treatment outcomes across numerous medical settings, including orthopedics, decreased risk of litigation, and higher patient ratings of the quality of care.^17,18 Various factors, including meeting of expectations, staff politeness, the communication skills of the surgeon, and waiting times, have been suggested to influence eventual patient satisfaction within the surgical literature.^19-21 However, within orthopedic surgery there is a paucity of investigations evaluating how patients determine preferences and satisfaction with the process of care.

The purpose of this study is to determine what preferences, if any, patients have when selecting their physician and how they experience care in an outpatient orthopedic setting. The authors hypothesize that the majority of patients find their physicians through online rating sites or recommendations from family and friends. The authors believe that patients expect to be seen in <30 minutes and will be unsatisfied overall with the amount of time that they spend with their physician.

Continue to: METHODS...

METHODS

The senior author (BRL) and a research team created a 15-question survey to evaluate patient preferences regarding the demographic characteristics (eg, age, gender, ethnicity) of their physician, wait times in a waiting room, time spent with the physician, care received from physician extenders (eg, nurse practitioners, physician assistants), and how they learned of their physician (Appendix). An a priori power analysis was conducted to determine that approximately 200 patients were needed for inclusion.^11,22 Following Institutional Review Board approval (ORA 15051104), the survey was administered to 212 patients in a single-surgeon, adult reconstruction clinic. The survey was digitally administered on a touch-screen tablet using an electronic independent third party survey center (SurveyMonkey Inc) devoid of any identifying data. The survey was offered to all patients >21 years of age who were English-speaking and in the common area as patients waiting to be seen, from June 2015 to March 2016. A research assistant approached patients in the waiting room and asked if they would like to participate in a short survey regarding what factors influence the patient-physician relationship from the patient’s perspective.

Appendix 1

1. Do you wish to partake in this 3-minute survey?
   1.  
   2.  

1. Have you had a prior knee or hip replacement?
   1.  
   2.  

1. What is your age?
   1. 30-40 years
   2. 40-50 years
   3. 50-60 years
   4. 60-70 years
   5. 70-80 years
   6. 80+ years

1. What is your gender?
   1.  
   2.  

1. Which of the following best represents your racial or ethnic heritage?
   1. African American
   2.  
   3.  
   4.  
   5.  

1. How much time would you like the doctor to spend talking to you on a routine visit?
   1. 0-5 minutes
   2. 5-10 minutes
   3. 10-15 minutes
   4. 15-20 minutes
   5. 20-30 minutes
   6. >30 minutes

1. How long is too long to wait to see the doctor?
   1. 10 minutes
   2. 20 minutes
   3. 30 minutes
   4. 40 minutes
   5. 50 minutes
   6. An hour or more

1. If you were to only see a physician’s assistant or nurse practitioner at your follow-up visit and not the doctor, would you feel like you were getting below average care?
   1.  
   2.  

1. Overall I am satisfied with the time the doctor spends with me.
   1.  
   2.  

1. If you were to need a major surgery, would you want the physician to tell you what he or she would do if they were in your shoes?
   1.  
   2.  

1. Would you prefer your doctor to be the same race/ethnicity as you?
   1. No
   2.  
   3. No Preference

1. Would you feel more comfortable with a male as opposed to a female orthopedic surgeon?
   1.  
   2.  

1. Would you feel more comfortable with a female as opposed to a male orthopedic surgeon?
   1.  
   2.  

1. What age would you like your physician to be?
   1. 25-35 years old
   2. 35-45 years old
   3. 45-55 years old
   4. 55-65 years old
   5. 65 years and older
   6. No preference

1. How do you usually find your physician?
   1.  
   2. Friends’ recommendations
   3. Healthcare provider’s recommendations
   4. Insurance plans
   5. Online research/ratings
   6. Other

Descriptive statistics were used to analyze subject demographics and survey responses. Chi-square analyses and multinomial logistic regressions were utilized to compare responses. All statistical analyses were conducted using SPSS version 24.0 software (SPSS Inc). Statistical significance was set at P < 0.05.

RESULTS

Of the 212 patients who were invited to participate, 196 patients (92.4%) agreed and completed the survey. Demographic and surgical history information can be found in Table 1. The majority of patients were female (62%) and above the age of 50 years (92.4%). Almost half (48.5%) of patients had a prior hip or knee replacement.

Table 1. Survey Respondent Demographics

When asked how long is too long to wait to see the doctor, 30 minutes (39.8%) was most commonly selected, followed by 40 minutes (24.5%) (Figure 1). When asked how much time patients would like the doctor to spend with them during an office visit, the majority (68.9%) selected either 10 to 15 minutes (41.3%) or 15 to 20 minutes (27.6%) (Figure 2). The majority of patients (92.3%) were satisfied with the amount of time the doctor spent with them. In addition, 94.9% of respondents would want their doctor to tell them what they would do if they were in the patient’s shoes when making decisions regarding their medical care (Table 2). Less than half of respondents (41.8%) believe that seeing a physician extender (eg, nurse practitioner or physician assistant) at a postoperative visit would result in a lower quality of care (Table 2).

Table 2. Responses to Survey Questions

When asked if patients preferred a doctor of the same race/ethnicity, the vast majority (83.7%) had no preference (Table 2). There was no significant difference found between male and female respondents when asked if they would feel more comfortable with a male as opposed to a female orthopedic surgeon (P = .118) and vice versa (P = .604) (Table 3). Most patients preferred a physician between the ages of 45 and 55 years (39.3%), followed by 35 and 45 years (23.0%); however, this preference was not statistically significant (Table 4). Older patients were more likely to prefer younger physicians (odds ratio, 4.612 for 25-35 years of age; odds ratio, 1.328 for 35-45 years of age). Only 12.2% of patients reported online research/rating sites as the main resource utilized when selecting their physician (Figure 3). The majority (68.4%) reported that recommendations from either friends (35.2%) or healthcare providers (33.2%) were the main avenues through which they found their physicians.

Table 3. Overall Responses to Questions Regarding Male and Female Orthopedic Surgeons^a

^aResponses were broken down by gender and compared utilizing a 2 x 2 chi-square analysis to test for significant differences in respondents’ gender preferences for their orthopedic surgeon.

Table 4. Patient Preferences Regarding Physician Age

^aNo preference was used as the reference category for the answer choices, while the age bracket “>80 years” was used as the reference for the age of respondent variable.

Continue to: DISCUSSION... 

DISCUSSION

The results of this study demonstrate that patients have several expectations and preferences with regards to the care they receive from physicians in the office. Patients prefer to wait <30 minutes before seeing their provider and desire only 10 to 20 minutes with their doctor. Patients do not have specific preferences with regards to the gender or ethnicity of their physician but would prefer a physician in the middle of their career, aged 45 to 55 years. Ultimately, patients do believe that seeing a physician at a postoperative visit is important, as just under half of patients thought that seeing a physician extender alone at a postoperative visit resulted in a lower quality of care.

While these results were obtained in a population specifically seeking the care of an orthopedic adult reconstruction surgeon, the results demonstrate that patients do not necessarily desire an unreasonable amount of time with their doctor. Patients simply want to be seen in a timely fashion and receive the full undivided attention of their doctor for approximately 20 minutes. Similarly, Patterson and colleagues²² found, in their series of 182 patients who presented to an orthopedic surgeon, that there was a significant correlation between time spent with the surgeon and overall patient satisfaction. Interestingly, the authors reported that patient satisfaction was not correlated with education level, sex, marital status, whether the patients were evaluated by a resident physician before seeing the attending surgeon, self-reported mental status, tobacco usage, the type of clinic visit, or the waiting time to see the surgeon (average, about 40 minutes for this cohort).²² Similarly, Teunis and colleagues²³ reported an average 32-minute wait time in 81 patients presenting for care at an orthopedic hand clinic and demonstrated that a longer wait time was associated with decreased patient satisfaction. These results corroborate the findings of this study that a short wait time is important to patients when evaluating the process of care. Additionally, patients do not have unreasonable expectations with regards to the amount of time they would like to spend with the physician. A physician who has a clinic for 9 hours a day would thus be able to see 54 patients and still spend at least 10 minutes with each patient. The quality of the physician-patient interaction is likely more important than the actual amount of time spent; however, based on this study, patients do have certain expectations about how much time physicians should spend with them.

There were no significant sex, age, or ethnicity preferences in our specific patient cohort. However, a sizable percentage of respondents, 41.8%, believed that they were receiving inferior care if they only saw a physician extender at a routine follow-up visit. Many orthopedic surgeons rely on the care provided by physician extenders to enable them to see additional patients. Physician extenders are well trained to provide high-quality care, including at routine postoperative visits. The results of this study, that many patients believe physician extenders provide lower-quality care, may be a result of inadequate patient education regarding the extensive training and education physician extenders undergo. Physician extenders are qualified, licensed healthcare professionals who are playing increasingly important roles within orthopedics and medicine as a whole. As the demand for orthopedic surgeons to see more patients increases, so does the role of physician extenders. Future research is warranted into educating the public regarding the importance of these healthcare providers and the adequacy of their training.

While many practices now routinely obtain patient satisfaction scores, another modality through which patients can express their satisfaction and experiences with healthcare providers is through online internet physician rating sites (IPRS). These sites have exploded in number and popularity in recent years and, according to some studies, have a very real effect on provider selection.²⁴ Interestingly, a low percentage of patients in this study utilized IPRS reviews to find their doctors. In a recent prospective survey study of 1000 consecutive patients presenting for care at the Mayo Clinic, Burkle and Keegan²⁴ reported that 27% of patients would choose not to see a physician based on a negative IPRS review. Interestingly, only 1.0% of patients reported finding their doctor through advertising. Numerous authors have recently addressed advertising in orthopedic surgery, specifically direct-to-consumer marking, including the influence of physician self-promotion on patients.^25,26 Specifically, Halawi and Barsoum²⁶ discussed how direct-to-consumer marketing is commonly disseminated to the public through television and print advertisements, which are modalities more commonly utilized by older generations. However, many advertising agencies are moving toward internet-based advertising, especially through orthopedic group and individual surgeon websites for self-promoting advertisement, as approximately 75% of Americans use the internet for health-related information.^25,27 The fact that many patients in this study did not utilize IPRS reviews or advertising (much of which is electronic) may be a result of the older, less internet-centric demographic that is often seen in an adult reconstruction clinic. Future research is warranted to determine what demographic of patients value IPRS reviews and how those reviews influence physician selection and the patient experience. 

There are several limitations to this study. First, the majority of the surveyed population was Caucasian, and our results may not be equally reflective of diverse ethnic backgrounds. Second, the cohort size, while based on previous studies conducted in a similar fashion, may be underpowered to detect significant differences for 1 or more of these questions. In addition, having a question regarding the patient’s medical background or experiences may have provided further insight as to why patients selected the answers that they did. Furthermore, questions regarding the patient’s education level, religious background, and income brackets may have provided further context in which to evaluate their responses. These questions were omitted in an effort to keep the questionnaire at a length that would maximize enrollment and prevent survey fatigue. Future research is warranted to determine what patient-specific, injury/symptom-specific, and treatment-specific variables influence the subjective patient experience.

CONCLUSION

The vast majority of patients desire only 10 to 20 minutes with their doctor and are highly satisfied with the amount of time their surgeon spends with them. Patients reported no significant gender- or ethnicity-based preferences for their doctor. The majority of patients believe that a wait time exceeding 30 minutes is too long. A greater effort needs to be made to educate patients and the public about the significant and effective roles nurse practitioners and physician assistants can play within the healthcare system. While this cohort did not report notable utilization of IPRS reviews, it remains essential to understand what factors influence patients’ subjective experiences with their providers to ensure that patients achieve their desired outcomes, and report as such on these websites as they continue to gain popularity. Diminishing clinic wait times and understanding patient preferences may lead to a greater percentage of “satisfied” patients. While the majority of focus has been and will likely continue to be on improving patients’ satisfaction with their outcomes, more work needs to be done focusing specifically on the process through which outcomes are achieved.

Hip and groin injuries in soccer players can be separated into 3 main categories based on the Doha Agreement:⁶ (1) defined clinical entities for groin pain, (2) hip-related groin pain, and (3) other causes of groin pain in athletes. Defined clinical entities include adductor-related, iliopsoas-related, inguinal-related (sports hernia/athletic pubalgia), and pubic-related groin pain; while hip-related groin pain includes hip morphologic abnormalities, labral tears, and chondral injuries. Included in other causes of groin pain are injuries not clinically defined. The Doha Agreement has acknowledged that not all causes of groin pain fit into the classification system including injuries of the rectus femoris, but they will be included under defined clinical entities for groin pain in this review. While they are not a cause of groin pain, proximal hamstring and gluteal and piriformis injuries are important causes of posterior and lateral hip pain in soccer players and will also be covered in the first section of this review.

DEFINED CLINICAL ENTITIES FOR GROIN PAIN IN SOCCER ATHLETES

ADDUCTOR-RELATED GROIN PAIN

Acute groin pain in soccer players is most commonly caused by muscle strain.⁷ Of the muscle strains, 66% involve the adductor longus, 25% the iliopsoas, and 23% the rectus femoris.⁷ The Doha Agreement defines adductor-related groin pain as adductor tenderness and pain on resisted adduction.⁶ Adductor longus strains in soccer players are typically noncontact injuries (62.5%) and most commonly the result of kicking (40%).^7-9 Many athletes will remember a pop at the time of the original injury.⁹ The combination of history and physical examination is usually sufficient for diagnosis; however, magnetic resonance imaging (MRI) may be helpful in complicated situations with a reported 86% sensitivity and 89% specificity.¹⁰ The average playing time lost is 2 weeks.⁵ Management includes rest, anti-inflammatory medication, physical therapy with core strengthening, and avoidance of aggressive stretching. While partial and distal avulsions can heal with conservative measures, proximal osseous and retracted avulsions of the adductor longus can be treated surgically.¹¹

Continue to: ILIOPSOAS-RELATED GROIN PAIN...

Iliopsoas strains account for 25% of acute groin strains and typically result from an impact that causes eccentric overload while kicking the ball.^7,12 Iliopsoas-related groin pain is defined by the Doha Agreement as groin pain that is reproducible with resisted hip flexion or hip flexor stretch.⁶ Iliopsoas strains respond well to conservative treatment such as rest, anti-inflammatory medication, and physical therapy. Rarely do these athletes become surgical candidates in the acute setting. Chronic cases of iliopsoas pathology occasionally require an arthroscopic intervention.

INGUINAL-RELATED GROIN PAIN

Inguinal-related groin pain is one of the most misleading diagnoses in sports because of its poorly defined and under-researched nature. The varying nomenclature of this entity illustrates the heterogeneity and includes sports hernia,^9,13-15 athletic pubalgia,¹⁶ core muscle injury,¹⁷ athletic hernia,¹⁸ Gilmore’s groin,¹⁵ osteitis pubis,¹⁹ sportsman’s hernia,^20,21 sportsmen’s groin,²² symphysis syndrome,²³ and inguinal disruption.²⁴ It is important to realize that in inguinal-related groin pain, regardless of the nomenclature, there is no true hernia present. The Doha Agreement has defined inguinal-related groin pain as “pain in the location of the inguinal region with associated tenderness of the inguinal canal,” which “is more likely if the pain is aggravated with resistance testing of the abdominal muscles or on Valsalva/cough/sneeze.”⁶ The condition is a painful soft tissue injury in the groin or inguinal area, involving a constellation of various anatomic areas including the abdominal musculature, sacroiliac joint, neural structures, pubic symphysis, adductors, and hip joint. This may account for up to 50% of chronic groin pain.^25,26

One important theory in the development of inguinal-related groin pain is its relationship with femoroacetabular impingement (FAI). Cadaver studies demonstrate that cam deformities cause a 35% increase in motion at the pubic symphysis altering the biomechanics of the adductors and abdominal musculature and, with repetitive stress, may lead to tearing or attenuation of the transversalis fascia, rectus abdominis, internal obliques, and/or external obliques.^12,27,28 Another prevailing theory of this is that the increased pubic stress causes weakness in the posterior portion of the inguinal canal, which then stretches and entraps the genitofemoral, ilioinguinal, lateral femoral cutaneous, or obturator nerves, ultimately causing pain.^28,29

Physical examination findings include pain over the conjoined tendon, pubic tubercle/symphysis (present in 22% of patients), adductor origin (36%), and inguinal ring.^25,30 Pain with resisted sit-ups is present in 46% of patients and pain with coughing/Valsalva is present in 10%.^25,30,31 Selective injections can be a critical part of the evaluation to differentiate inguinal-related groin pain from FAI, osteitis pubis, and adductor strains while helping to determine the appropriate treatment.^25,32 The role of advanced imaging is unclear as the clinical entity is still uncertain and the standard imaging findings have not been definitively established.³³ However, several studies have reported MRI findings suggestive of inguinal-related groin pain. One of the more common MRI findings is the “secondary cleft sign,” which requires injecting a dye into the pubic symphysis.³⁴ Several studies have shown that the radiographic dye extravasates preferentially into the side where the groin symptoms exist and are thought to be secondary to micro-tearing at the common attachment of the musculotendinous structures to the anterior pubis.^34,35 However, it should be noted that the lack of imaging findings does not exclude the possibility of inguinal-related groin pathology.

Initial treatment consists of rest, anti-inflammatory medication, injections, and physical therapy with core strengthening.²⁵ A study by Paajanen and colleagues³⁶ suggested that early surgical intervention may be preferred over conservative management in a randomized trial comparing physical therapy, injections, anti-inflammatory medication, and rest vs an extraperitoneal laparoscopic mesh repair behind the pubic symphysis. In the conservative group, 20% of athletes returned to sport at 1 month, 27% at 3 months, and 50% at 12 months.³⁶ In comparison, the surgical group had 67% return to sport at 1 month, 90% at 3 months, and 97% at 12 months.³⁶ If surgical management is chosen, there are a variety of surgical options including laparoscopy, open or mini-open repairs of the abdominal musculature/fascia or pelvic floor with and without mesh, neurolysis, and adductor release. Muschawek and Berger³⁷described a series of 129 patients that had an open-suture repair of the posterior wall of the inguinal canal with 67% of professional athletes returning to sport within 2 weeks and 83.7% of athletes returning to sport overall. The rates of return to play are consistently 80% to 100% without demonstrated superiority of one technique over another up to this point.³⁰

Continue to: PUBIC-RELATED GROIN PAIN...

Pubic-related groin pain is defined as tenderness to palpation over the pubic symphysis and adjacent bone.⁶ Osteitis pubis is a chronic overuse injury characterized by localized pain to the pubic symphysis and is believed to be caused by repetitive microtrauma from a dynamic rotation of the sacroiliac joint with suggested imbalances between the rectus abdominis and the adductor musculature.^12,38 In soccer players, the condition may be related to the constant torsional stresses of kicking, running, or twisting.¹² If performed, radiographs often show lytic areas of the pubic symphysis, widening of the symphysis, sclerosis, and cystic changes, while bone marrow edema may be present on MRI.³⁸Management consists of rest, anti-inflammatory medication, and corticosteroid injections with gentle stretching once asymptomatic.^12,39

RECTUS FEMORIS INJURIES

The most common injury to the rectus femoris is a strain as a result of an eccentric overload while a soccer player is hit trying to extend his or her leg to kick a ball.¹² In pediatric soccer athletes, an avulsion of the anterior inferior iliac spine from the direct head of the rectus femoris is the second most common avulsion injury.⁴⁰ Radiographs are diagnostic and can help determine treatment. Most avulsions are minimally displaced and can be treated conservatively, but surgical intervention should be considered for an avulsion >2 cm.¹²

PROXIMAL HAMSTRING INJURIES

Proximal hamstring injuries are important causes of acute posterior hip pain and are caused by an eccentric overload in hip flexion and knee extension.²⁵ In soccer players, the typical mechanism is that the planted leg slipping on the playing turf creates a sudden violent flexion of the hip with the knee in an extended position. While relatively uncommon, when a significant avulsion occurs in a professional athlete, surgical intervention is often necessary. In general, these injuries may involve partial or full avulsions off the ischial tuberosity or separation of the bony apophysis in pediatric athletes. A physical examination in the acute setting typically demonstrates massive posterior thigh ecchymosis, a palpable defect, and/or weakness with knee flexion. Imaging is helpful to confirm the diagnosis and evaluate for surgical repair. Radiographs may show a bony avulsion, which is more commonly seen in pediatric apophyseal avulsions. MRI can be used to differentiate a complete tear (involving all 3 tendons) vs a partial tear and evaluate for retraction of the tendon distally. Complete and partial tears of 2 tendons with retraction of >2 cm should be surgically repaired.²⁵ Partial tears without tendon retraction may be treated conservatively with rest, anti-inflammatory medication, and physical therapy and then followed later by a hamstring prevention program.²⁵ We have found that biologic augmentation with platelet-rich plasma can help accelerate healing in partial thickness injuries; however, the evidence is conflicting.

GLUTEAL INJURIES

Chronic overuse injuries of the gluteal musculature are common causes of lateral hip pain. Abductor overuse caused by weakness in the gluteus medius with a normal tensor fascia lata can cause pain with sitting and side-lying.²⁵Overuse of the gluteal muscles with muscular imbalances along with increased tension on the iliotibial band can lead to greater trochanteric pain syndrome.²⁵ A physical examination may demonstrate tenderness over the greater trochanter bursa and positive flexion, abduction, and external rotation testing.²⁵ Abductor overuse syndrome and greater trochanteric pain syndrome are best treated with anti-inflammatory medication and physical therapy to balance the core/pelvic musculature.⁴¹

PIRIFORMIS INJURIES

Piriformis syndrome is a compressive neuropathy of the sciatic nerve. The mechanism of injury in the athlete is through a minor trauma to the buttock or pelvis.^25,42,43 Presenting symptoms include pain with sitting and internal rotation of the hip.¹² Zeren and colleagues⁴² published the only study that includes 2 cases of bilateral piriformis syndrome in professional soccer players. The diagnosis was confirmed with electromyography that was negative at rest and positive when measured after running.⁴² The athletes exhausted conservative treatment with physical therapy, anti-inflammatory medications, injections, and rest and were treated with surgical decompression.⁴² Both players returned to professional soccer after 6 months and played for an average of 7 years.⁴²

Continue to: HIP-RELATED GROIN PAIN IN SOCCER ATHLETES...

HIP-RELATED GROIN PAIN IN SOCCER ATHLETES

Hip-related groin pain has garnered more attention in the last several years after being a previously underdiagnosed entity. One study found that practitioners treated groin pain in athletes for 7 months on average before recognizing that the pathology was intra-articular.⁴⁴ FAI, labral tears, and chondral injuries are the major intra-articular pathologies that cause groin pain in athletes and ultimately impaired performance.^45,46

FEMOROACETABULAR IMPINGEMENT

FAI is caused by pincer-type, cam-type, or combined-type deformities. Pincer lesions are defined as an increased acetabular overhang, while cam lesions are described as an increased bone at the femoral head/neck junction. These deformities in isolation or in combination cause decreased hip motion and increased contact pressures between the anterolateral acetabulum and femoral head-neck junction, which may ultimately lead to labral tears, chondral lesions, and osteoarthritis.⁴⁷ During hip flexion, cam deformities impact the anterolateral acetabulum, preferentially causing articular cartilage damage, while sparing the labrum.²⁵ Conversely, pincer deformities cause repetitive microtrauma to the labrum, crushing it between the acetabular rim and femoral neck with secondary damage to the articular cartilage.²⁵ Over time, the damage to the labrum and articular cartilage may lead to premature osteoarthritis, which occurs at a much younger age in the athletic population.⁴⁸

We know from previous studies that soccer athletes have a high prevalence of morphologic abnormalities of the hip, most commonly FAI. Gerhardt and colleagues⁴⁹ documented the prevalence of hip morphologic abnormalities in elite soccer players and found abnormalities in 72% of men and over 50% of women. It should be noted that this series looked at asymptomatic athletes; however, it has been shown that hip dysmorphia is a risk factor for hip and groin injuries and may provide an opportunity for injury prevention strategies.⁵⁰

Physical examination findings in FAI include decreased hip internal rotation and pain with provocative testing. Wyss and colleagues⁵¹ measured hip internal rotation in athletes with and without FAI. They found that the athletes with FAI have an average of 4° of internal rotation compared with that of the non-FAI athletes with 28°.⁵¹ A worsening internal rotation deficit has been linked to increasing severity of the deformity and when <20° was correlated with joint damage.⁵¹ Provocative testing has a high sensitivity with a recent meta-analysis demonstrating the most sensitive tests to be the anterior impingement test (flexion-adduction-internal rotation) with 94% to 99% sensitivity and the flexion-internal rotation test with 96% sensitivity.⁵² While provocative tests are sensitive, there is no current consensus on physical examination findings that are specific in the diagnosis of FAI.⁶ Diagnosis is made with both positive physical examination and radiographic morphologic findings (alpha angle >55°).³³ Advanced imaging with an MRI arthrogram can be helpful in diagnosing underlying injuries such as labral tears in athletes presenting with compatible symptoms.

Symptomatic patients are typically treated surgically through either open or arthroscopic procedures, which have favorable and comparable functional results, biomechanics, and return to sport.⁵³ In soccer players, return to sport at the professional level after arthroscopic surgery was found to be 96%.⁵⁴ Players returned to sport on average 9.2 months postoperatively and played an average of 70 games after surgery.⁵⁴

Continue to: LABRAL TEARS...

Labral tears present with groin pain, limited hip range of motion, and symptoms of catching, locking, and instability.²⁵Causes of labral tears include trauma, FAI, hip dysplasia, capsular laxity, and degeneration.⁵⁵ Labral tears rarely occur in isolation and have a high association (87%) with morphologic abnormalities of the hip, most commonly FAI and occasionally dysplasia.^56,57 Physical examination findings include positive anterior impingement tests (flexion-adduction-internal rotation) in athletes with anterior labral tears and, less commonly, positive flexion, abduction, and external rotation tests for athletes with lateral and posterolateral labral tears.⁵⁷ Radiographic imaging is used to evaluate for concurrent morphologic abnormalities of the hip, and MRI arthrogram is used to confirm the diagnosis of a labral tear with a sensitivity of 76% to 91%.⁵⁸ Initial treatment consists of conservative treatment, which includes rest, anti-inflammatory medication, activity modification, and physical therapy. In patient refractory to conservative treatment, arthroscopic surgery is effective with high rates of return to sport.⁵⁹ It is important to note that when treating labral tears surgically, any morphologic abnormality needs to be addressed to prevent recurrence of the tear.

CHONDRAL INJURIES

Focal chondral lesions in the hip are commonly found in athletes with FAI and labral tears during arthroscopic evaluation.⁶⁰ Full-thickness defects and unstable flaps in weight-bearing areas are indications for surgical intervention with microfracture.⁶⁰ There are no studies examining the efficacy of microfracture in isolation; however, Locks and colleagues⁵⁴ have demonstrated a 96% return to professional soccer after an arthroscopic treatment for FAI and found that severe chondral damage with microfracture did not lengthen the return to sport.

RELATIONSHIP BETWEEN INGUINAL-RELATED GROIN PAIN AND FEMOROACETABULAR IMPINGEMENT

The altered biomechanics and restricted range of motion in athletes with FAI cause an increase in compensatory motion at the pelvis and lumbosacral areas, which may contribute to the development of inguinal-related groin pain, bursitis, adductor, and gluteal dysfunction.²⁵ In athletes with concurrent intra-articular hip pathology and inguinal-related groin pain, treating 1 condition in isolation will result in poor results. Larson and colleagues⁶¹ found that when only inguinal-related groin pain or FAI were addressed, return to sport was only 25% and 50%, respectively, while concurrent surgical treatment resulted in a return to sport of 89%.

DISCUSSION AND FUTURE DIRECTIONS

Groin injuries in soccer players can cause significant decreases in athletic performance, result in lost playing time, and may ultimately need a surgical intervention. Efforts are underway to determine the role and efficacy of identifying high-risk athletes that may benefit from targeted prevention strategies. Wyles and colleagues⁴⁸ identified adolescent athletes with hip internal rotation of <10° and found at 5-year follow-up that 95% had abnormal MRI findings compared with 54% in the age-matched control group. Wollin and colleagues⁶² developed an in-season screening protocol using adductor strength reductions of 15%, adductor/abductor strength ratio <0.9, and hip and groin outcome scores <75 as indicators of at-risk individuals. By employing preseason and in-season screening protocols, we can identify high-risk athletes for further workup and close follow-up throughout the season. Pelvic radiographs in these high-risk athletes may help us determine the presence of abnormalities in hip morphology, which would place an athlete into a high-risk group where prevention strategies could then be employed. There are no data available to determine the most effective prevention strategy at this time. However, levels II and III evidence exists indicating that exercise programs may reduce the incidence of groin injuries.⁶³ Additional strategies, like limiting adolescent playing time similar to strategies employed in baseball pitches with pitch counts, could potentially reduce the potential for injury. Further studies on preseason screening and in-season monitoring protocols, targeted exercise therapy, early surgical intervention, and potential biologic intervention are needed to determine the most effective methods of preventing groin injuries in athletes.

Hip and groin injuries in soccer players can be separated into 3 main categories based on the Doha Agreement:⁶ (1) defined clinical entities for groin pain, (2) hip-related groin pain, and (3) other causes of groin pain in athletes. Defined clinical entities include adductor-related, iliopsoas-related, inguinal-related (sports hernia/athletic pubalgia), and pubic-related groin pain; while hip-related groin pain includes hip morphologic abnormalities, labral tears, and chondral injuries. Included in other causes of groin pain are injuries not clinically defined. The Doha Agreement has acknowledged that not all causes of groin pain fit into the classification system including injuries of the rectus femoris, but they will be included under defined clinical entities for groin pain in this review. While they are not a cause of groin pain, proximal hamstring and gluteal and piriformis injuries are important causes of posterior and lateral hip pain in soccer players and will also be covered in the first section of this review.

DEFINED CLINICAL ENTITIES FOR GROIN PAIN IN SOCCER ATHLETES

ADDUCTOR-RELATED GROIN PAIN

Acute groin pain in soccer players is most commonly caused by muscle strain.⁷ Of the muscle strains, 66% involve the adductor longus, 25% the iliopsoas, and 23% the rectus femoris.⁷ The Doha Agreement defines adductor-related groin pain as adductor tenderness and pain on resisted adduction.⁶ Adductor longus strains in soccer players are typically noncontact injuries (62.5%) and most commonly the result of kicking (40%).^7-9 Many athletes will remember a pop at the time of the original injury.⁹ The combination of history and physical examination is usually sufficient for diagnosis; however, magnetic resonance imaging (MRI) may be helpful in complicated situations with a reported 86% sensitivity and 89% specificity.¹⁰ The average playing time lost is 2 weeks.⁵ Management includes rest, anti-inflammatory medication, physical therapy with core strengthening, and avoidance of aggressive stretching. While partial and distal avulsions can heal with conservative measures, proximal osseous and retracted avulsions of the adductor longus can be treated surgically.¹¹

Continue to: ILIOPSOAS-RELATED GROIN PAIN...

Iliopsoas strains account for 25% of acute groin strains and typically result from an impact that causes eccentric overload while kicking the ball.^7,12 Iliopsoas-related groin pain is defined by the Doha Agreement as groin pain that is reproducible with resisted hip flexion or hip flexor stretch.⁶ Iliopsoas strains respond well to conservative treatment such as rest, anti-inflammatory medication, and physical therapy. Rarely do these athletes become surgical candidates in the acute setting. Chronic cases of iliopsoas pathology occasionally require an arthroscopic intervention.

INGUINAL-RELATED GROIN PAIN

Inguinal-related groin pain is one of the most misleading diagnoses in sports because of its poorly defined and under-researched nature. The varying nomenclature of this entity illustrates the heterogeneity and includes sports hernia,^9,13-15 athletic pubalgia,¹⁶ core muscle injury,¹⁷ athletic hernia,¹⁸ Gilmore’s groin,¹⁵ osteitis pubis,¹⁹ sportsman’s hernia,^20,21 sportsmen’s groin,²² symphysis syndrome,²³ and inguinal disruption.²⁴ It is important to realize that in inguinal-related groin pain, regardless of the nomenclature, there is no true hernia present. The Doha Agreement has defined inguinal-related groin pain as “pain in the location of the inguinal region with associated tenderness of the inguinal canal,” which “is more likely if the pain is aggravated with resistance testing of the abdominal muscles or on Valsalva/cough/sneeze.”⁶ The condition is a painful soft tissue injury in the groin or inguinal area, involving a constellation of various anatomic areas including the abdominal musculature, sacroiliac joint, neural structures, pubic symphysis, adductors, and hip joint. This may account for up to 50% of chronic groin pain.^25,26

One important theory in the development of inguinal-related groin pain is its relationship with femoroacetabular impingement (FAI). Cadaver studies demonstrate that cam deformities cause a 35% increase in motion at the pubic symphysis altering the biomechanics of the adductors and abdominal musculature and, with repetitive stress, may lead to tearing or attenuation of the transversalis fascia, rectus abdominis, internal obliques, and/or external obliques.^12,27,28 Another prevailing theory of this is that the increased pubic stress causes weakness in the posterior portion of the inguinal canal, which then stretches and entraps the genitofemoral, ilioinguinal, lateral femoral cutaneous, or obturator nerves, ultimately causing pain.^28,29

Physical examination findings include pain over the conjoined tendon, pubic tubercle/symphysis (present in 22% of patients), adductor origin (36%), and inguinal ring.^25,30 Pain with resisted sit-ups is present in 46% of patients and pain with coughing/Valsalva is present in 10%.^25,30,31 Selective injections can be a critical part of the evaluation to differentiate inguinal-related groin pain from FAI, osteitis pubis, and adductor strains while helping to determine the appropriate treatment.^25,32 The role of advanced imaging is unclear as the clinical entity is still uncertain and the standard imaging findings have not been definitively established.³³ However, several studies have reported MRI findings suggestive of inguinal-related groin pain. One of the more common MRI findings is the “secondary cleft sign,” which requires injecting a dye into the pubic symphysis.³⁴ Several studies have shown that the radiographic dye extravasates preferentially into the side where the groin symptoms exist and are thought to be secondary to micro-tearing at the common attachment of the musculotendinous structures to the anterior pubis.^34,35 However, it should be noted that the lack of imaging findings does not exclude the possibility of inguinal-related groin pathology.

Initial treatment consists of rest, anti-inflammatory medication, injections, and physical therapy with core strengthening.²⁵ A study by Paajanen and colleagues³⁶ suggested that early surgical intervention may be preferred over conservative management in a randomized trial comparing physical therapy, injections, anti-inflammatory medication, and rest vs an extraperitoneal laparoscopic mesh repair behind the pubic symphysis. In the conservative group, 20% of athletes returned to sport at 1 month, 27% at 3 months, and 50% at 12 months.³⁶ In comparison, the surgical group had 67% return to sport at 1 month, 90% at 3 months, and 97% at 12 months.³⁶ If surgical management is chosen, there are a variety of surgical options including laparoscopy, open or mini-open repairs of the abdominal musculature/fascia or pelvic floor with and without mesh, neurolysis, and adductor release. Muschawek and Berger³⁷described a series of 129 patients that had an open-suture repair of the posterior wall of the inguinal canal with 67% of professional athletes returning to sport within 2 weeks and 83.7% of athletes returning to sport overall. The rates of return to play are consistently 80% to 100% without demonstrated superiority of one technique over another up to this point.³⁰

Continue to: PUBIC-RELATED GROIN PAIN...

Pubic-related groin pain is defined as tenderness to palpation over the pubic symphysis and adjacent bone.⁶ Osteitis pubis is a chronic overuse injury characterized by localized pain to the pubic symphysis and is believed to be caused by repetitive microtrauma from a dynamic rotation of the sacroiliac joint with suggested imbalances between the rectus abdominis and the adductor musculature.^12,38 In soccer players, the condition may be related to the constant torsional stresses of kicking, running, or twisting.¹² If performed, radiographs often show lytic areas of the pubic symphysis, widening of the symphysis, sclerosis, and cystic changes, while bone marrow edema may be present on MRI.³⁸Management consists of rest, anti-inflammatory medication, and corticosteroid injections with gentle stretching once asymptomatic.^12,39

RECTUS FEMORIS INJURIES

The most common injury to the rectus femoris is a strain as a result of an eccentric overload while a soccer player is hit trying to extend his or her leg to kick a ball.¹² In pediatric soccer athletes, an avulsion of the anterior inferior iliac spine from the direct head of the rectus femoris is the second most common avulsion injury.⁴⁰ Radiographs are diagnostic and can help determine treatment. Most avulsions are minimally displaced and can be treated conservatively, but surgical intervention should be considered for an avulsion >2 cm.¹²

PROXIMAL HAMSTRING INJURIES

Proximal hamstring injuries are important causes of acute posterior hip pain and are caused by an eccentric overload in hip flexion and knee extension.²⁵ In soccer players, the typical mechanism is that the planted leg slipping on the playing turf creates a sudden violent flexion of the hip with the knee in an extended position. While relatively uncommon, when a significant avulsion occurs in a professional athlete, surgical intervention is often necessary. In general, these injuries may involve partial or full avulsions off the ischial tuberosity or separation of the bony apophysis in pediatric athletes. A physical examination in the acute setting typically demonstrates massive posterior thigh ecchymosis, a palpable defect, and/or weakness with knee flexion. Imaging is helpful to confirm the diagnosis and evaluate for surgical repair. Radiographs may show a bony avulsion, which is more commonly seen in pediatric apophyseal avulsions. MRI can be used to differentiate a complete tear (involving all 3 tendons) vs a partial tear and evaluate for retraction of the tendon distally. Complete and partial tears of 2 tendons with retraction of >2 cm should be surgically repaired.²⁵ Partial tears without tendon retraction may be treated conservatively with rest, anti-inflammatory medication, and physical therapy and then followed later by a hamstring prevention program.²⁵ We have found that biologic augmentation with platelet-rich plasma can help accelerate healing in partial thickness injuries; however, the evidence is conflicting.

GLUTEAL INJURIES

Chronic overuse injuries of the gluteal musculature are common causes of lateral hip pain. Abductor overuse caused by weakness in the gluteus medius with a normal tensor fascia lata can cause pain with sitting and side-lying.²⁵Overuse of the gluteal muscles with muscular imbalances along with increased tension on the iliotibial band can lead to greater trochanteric pain syndrome.²⁵ A physical examination may demonstrate tenderness over the greater trochanter bursa and positive flexion, abduction, and external rotation testing.²⁵ Abductor overuse syndrome and greater trochanteric pain syndrome are best treated with anti-inflammatory medication and physical therapy to balance the core/pelvic musculature.⁴¹

PIRIFORMIS INJURIES

Piriformis syndrome is a compressive neuropathy of the sciatic nerve. The mechanism of injury in the athlete is through a minor trauma to the buttock or pelvis.^25,42,43 Presenting symptoms include pain with sitting and internal rotation of the hip.¹² Zeren and colleagues⁴² published the only study that includes 2 cases of bilateral piriformis syndrome in professional soccer players. The diagnosis was confirmed with electromyography that was negative at rest and positive when measured after running.⁴² The athletes exhausted conservative treatment with physical therapy, anti-inflammatory medications, injections, and rest and were treated with surgical decompression.⁴² Both players returned to professional soccer after 6 months and played for an average of 7 years.⁴²

Continue to: HIP-RELATED GROIN PAIN IN SOCCER ATHLETES...

HIP-RELATED GROIN PAIN IN SOCCER ATHLETES

Hip-related groin pain has garnered more attention in the last several years after being a previously underdiagnosed entity. One study found that practitioners treated groin pain in athletes for 7 months on average before recognizing that the pathology was intra-articular.⁴⁴ FAI, labral tears, and chondral injuries are the major intra-articular pathologies that cause groin pain in athletes and ultimately impaired performance.^45,46

FEMOROACETABULAR IMPINGEMENT

FAI is caused by pincer-type, cam-type, or combined-type deformities. Pincer lesions are defined as an increased acetabular overhang, while cam lesions are described as an increased bone at the femoral head/neck junction. These deformities in isolation or in combination cause decreased hip motion and increased contact pressures between the anterolateral acetabulum and femoral head-neck junction, which may ultimately lead to labral tears, chondral lesions, and osteoarthritis.⁴⁷ During hip flexion, cam deformities impact the anterolateral acetabulum, preferentially causing articular cartilage damage, while sparing the labrum.²⁵ Conversely, pincer deformities cause repetitive microtrauma to the labrum, crushing it between the acetabular rim and femoral neck with secondary damage to the articular cartilage.²⁵ Over time, the damage to the labrum and articular cartilage may lead to premature osteoarthritis, which occurs at a much younger age in the athletic population.⁴⁸

We know from previous studies that soccer athletes have a high prevalence of morphologic abnormalities of the hip, most commonly FAI. Gerhardt and colleagues⁴⁹ documented the prevalence of hip morphologic abnormalities in elite soccer players and found abnormalities in 72% of men and over 50% of women. It should be noted that this series looked at asymptomatic athletes; however, it has been shown that hip dysmorphia is a risk factor for hip and groin injuries and may provide an opportunity for injury prevention strategies.⁵⁰

Physical examination findings in FAI include decreased hip internal rotation and pain with provocative testing. Wyss and colleagues⁵¹ measured hip internal rotation in athletes with and without FAI. They found that the athletes with FAI have an average of 4° of internal rotation compared with that of the non-FAI athletes with 28°.⁵¹ A worsening internal rotation deficit has been linked to increasing severity of the deformity and when <20° was correlated with joint damage.⁵¹ Provocative testing has a high sensitivity with a recent meta-analysis demonstrating the most sensitive tests to be the anterior impingement test (flexion-adduction-internal rotation) with 94% to 99% sensitivity and the flexion-internal rotation test with 96% sensitivity.⁵² While provocative tests are sensitive, there is no current consensus on physical examination findings that are specific in the diagnosis of FAI.⁶ Diagnosis is made with both positive physical examination and radiographic morphologic findings (alpha angle >55°).³³ Advanced imaging with an MRI arthrogram can be helpful in diagnosing underlying injuries such as labral tears in athletes presenting with compatible symptoms.

Symptomatic patients are typically treated surgically through either open or arthroscopic procedures, which have favorable and comparable functional results, biomechanics, and return to sport.⁵³ In soccer players, return to sport at the professional level after arthroscopic surgery was found to be 96%.⁵⁴ Players returned to sport on average 9.2 months postoperatively and played an average of 70 games after surgery.⁵⁴

Continue to: LABRAL TEARS...

Labral tears present with groin pain, limited hip range of motion, and symptoms of catching, locking, and instability.²⁵Causes of labral tears include trauma, FAI, hip dysplasia, capsular laxity, and degeneration.⁵⁵ Labral tears rarely occur in isolation and have a high association (87%) with morphologic abnormalities of the hip, most commonly FAI and occasionally dysplasia.^56,57 Physical examination findings include positive anterior impingement tests (flexion-adduction-internal rotation) in athletes with anterior labral tears and, less commonly, positive flexion, abduction, and external rotation tests for athletes with lateral and posterolateral labral tears.⁵⁷ Radiographic imaging is used to evaluate for concurrent morphologic abnormalities of the hip, and MRI arthrogram is used to confirm the diagnosis of a labral tear with a sensitivity of 76% to 91%.⁵⁸ Initial treatment consists of conservative treatment, which includes rest, anti-inflammatory medication, activity modification, and physical therapy. In patient refractory to conservative treatment, arthroscopic surgery is effective with high rates of return to sport.⁵⁹ It is important to note that when treating labral tears surgically, any morphologic abnormality needs to be addressed to prevent recurrence of the tear.

CHONDRAL INJURIES

Focal chondral lesions in the hip are commonly found in athletes with FAI and labral tears during arthroscopic evaluation.⁶⁰ Full-thickness defects and unstable flaps in weight-bearing areas are indications for surgical intervention with microfracture.⁶⁰ There are no studies examining the efficacy of microfracture in isolation; however, Locks and colleagues⁵⁴ have demonstrated a 96% return to professional soccer after an arthroscopic treatment for FAI and found that severe chondral damage with microfracture did not lengthen the return to sport.

RELATIONSHIP BETWEEN INGUINAL-RELATED GROIN PAIN AND FEMOROACETABULAR IMPINGEMENT

The altered biomechanics and restricted range of motion in athletes with FAI cause an increase in compensatory motion at the pelvis and lumbosacral areas, which may contribute to the development of inguinal-related groin pain, bursitis, adductor, and gluteal dysfunction.²⁵ In athletes with concurrent intra-articular hip pathology and inguinal-related groin pain, treating 1 condition in isolation will result in poor results. Larson and colleagues⁶¹ found that when only inguinal-related groin pain or FAI were addressed, return to sport was only 25% and 50%, respectively, while concurrent surgical treatment resulted in a return to sport of 89%.

DISCUSSION AND FUTURE DIRECTIONS

Groin injuries in soccer players can cause significant decreases in athletic performance, result in lost playing time, and may ultimately need a surgical intervention. Efforts are underway to determine the role and efficacy of identifying high-risk athletes that may benefit from targeted prevention strategies. Wyles and colleagues⁴⁸ identified adolescent athletes with hip internal rotation of <10° and found at 5-year follow-up that 95% had abnormal MRI findings compared with 54% in the age-matched control group. Wollin and colleagues⁶² developed an in-season screening protocol using adductor strength reductions of 15%, adductor/abductor strength ratio <0.9, and hip and groin outcome scores <75 as indicators of at-risk individuals. By employing preseason and in-season screening protocols, we can identify high-risk athletes for further workup and close follow-up throughout the season. Pelvic radiographs in these high-risk athletes may help us determine the presence of abnormalities in hip morphology, which would place an athlete into a high-risk group where prevention strategies could then be employed. There are no data available to determine the most effective prevention strategy at this time. However, levels II and III evidence exists indicating that exercise programs may reduce the incidence of groin injuries.⁶³ Additional strategies, like limiting adolescent playing time similar to strategies employed in baseball pitches with pitch counts, could potentially reduce the potential for injury. Further studies on preseason screening and in-season monitoring protocols, targeted exercise therapy, early surgical intervention, and potential biologic intervention are needed to determine the most effective methods of preventing groin injuries in athletes.

Hip and groin injuries in soccer players can be separated into 3 main categories based on the Doha Agreement:⁶ (1) defined clinical entities for groin pain, (2) hip-related groin pain, and (3) other causes of groin pain in athletes. Defined clinical entities include adductor-related, iliopsoas-related, inguinal-related (sports hernia/athletic pubalgia), and pubic-related groin pain; while hip-related groin pain includes hip morphologic abnormalities, labral tears, and chondral injuries. Included in other causes of groin pain are injuries not clinically defined. The Doha Agreement has acknowledged that not all causes of groin pain fit into the classification system including injuries of the rectus femoris, but they will be included under defined clinical entities for groin pain in this review. While they are not a cause of groin pain, proximal hamstring and gluteal and piriformis injuries are important causes of posterior and lateral hip pain in soccer players and will also be covered in the first section of this review.

DEFINED CLINICAL ENTITIES FOR GROIN PAIN IN SOCCER ATHLETES

ADDUCTOR-RELATED GROIN PAIN

Acute groin pain in soccer players is most commonly caused by muscle strain.⁷ Of the muscle strains, 66% involve the adductor longus, 25% the iliopsoas, and 23% the rectus femoris.⁷ The Doha Agreement defines adductor-related groin pain as adductor tenderness and pain on resisted adduction.⁶ Adductor longus strains in soccer players are typically noncontact injuries (62.5%) and most commonly the result of kicking (40%).^7-9 Many athletes will remember a pop at the time of the original injury.⁹ The combination of history and physical examination is usually sufficient for diagnosis; however, magnetic resonance imaging (MRI) may be helpful in complicated situations with a reported 86% sensitivity and 89% specificity.¹⁰ The average playing time lost is 2 weeks.⁵ Management includes rest, anti-inflammatory medication, physical therapy with core strengthening, and avoidance of aggressive stretching. While partial and distal avulsions can heal with conservative measures, proximal osseous and retracted avulsions of the adductor longus can be treated surgically.¹¹

Continue to: ILIOPSOAS-RELATED GROIN PAIN...

Iliopsoas strains account for 25% of acute groin strains and typically result from an impact that causes eccentric overload while kicking the ball.^7,12 Iliopsoas-related groin pain is defined by the Doha Agreement as groin pain that is reproducible with resisted hip flexion or hip flexor stretch.⁶ Iliopsoas strains respond well to conservative treatment such as rest, anti-inflammatory medication, and physical therapy. Rarely do these athletes become surgical candidates in the acute setting. Chronic cases of iliopsoas pathology occasionally require an arthroscopic intervention.

INGUINAL-RELATED GROIN PAIN

Inguinal-related groin pain is one of the most misleading diagnoses in sports because of its poorly defined and under-researched nature. The varying nomenclature of this entity illustrates the heterogeneity and includes sports hernia,^9,13-15 athletic pubalgia,¹⁶ core muscle injury,¹⁷ athletic hernia,¹⁸ Gilmore’s groin,¹⁵ osteitis pubis,¹⁹ sportsman’s hernia,^20,21 sportsmen’s groin,²² symphysis syndrome,²³ and inguinal disruption.²⁴ It is important to realize that in inguinal-related groin pain, regardless of the nomenclature, there is no true hernia present. The Doha Agreement has defined inguinal-related groin pain as “pain in the location of the inguinal region with associated tenderness of the inguinal canal,” which “is more likely if the pain is aggravated with resistance testing of the abdominal muscles or on Valsalva/cough/sneeze.”⁶ The condition is a painful soft tissue injury in the groin or inguinal area, involving a constellation of various anatomic areas including the abdominal musculature, sacroiliac joint, neural structures, pubic symphysis, adductors, and hip joint. This may account for up to 50% of chronic groin pain.^25,26

One important theory in the development of inguinal-related groin pain is its relationship with femoroacetabular impingement (FAI). Cadaver studies demonstrate that cam deformities cause a 35% increase in motion at the pubic symphysis altering the biomechanics of the adductors and abdominal musculature and, with repetitive stress, may lead to tearing or attenuation of the transversalis fascia, rectus abdominis, internal obliques, and/or external obliques.^12,27,28 Another prevailing theory of this is that the increased pubic stress causes weakness in the posterior portion of the inguinal canal, which then stretches and entraps the genitofemoral, ilioinguinal, lateral femoral cutaneous, or obturator nerves, ultimately causing pain.^28,29

Physical examination findings include pain over the conjoined tendon, pubic tubercle/symphysis (present in 22% of patients), adductor origin (36%), and inguinal ring.^25,30 Pain with resisted sit-ups is present in 46% of patients and pain with coughing/Valsalva is present in 10%.^25,30,31 Selective injections can be a critical part of the evaluation to differentiate inguinal-related groin pain from FAI, osteitis pubis, and adductor strains while helping to determine the appropriate treatment.^25,32 The role of advanced imaging is unclear as the clinical entity is still uncertain and the standard imaging findings have not been definitively established.³³ However, several studies have reported MRI findings suggestive of inguinal-related groin pain. One of the more common MRI findings is the “secondary cleft sign,” which requires injecting a dye into the pubic symphysis.³⁴ Several studies have shown that the radiographic dye extravasates preferentially into the side where the groin symptoms exist and are thought to be secondary to micro-tearing at the common attachment of the musculotendinous structures to the anterior pubis.^34,35 However, it should be noted that the lack of imaging findings does not exclude the possibility of inguinal-related groin pathology.

Initial treatment consists of rest, anti-inflammatory medication, injections, and physical therapy with core strengthening.²⁵ A study by Paajanen and colleagues³⁶ suggested that early surgical intervention may be preferred over conservative management in a randomized trial comparing physical therapy, injections, anti-inflammatory medication, and rest vs an extraperitoneal laparoscopic mesh repair behind the pubic symphysis. In the conservative group, 20% of athletes returned to sport at 1 month, 27% at 3 months, and 50% at 12 months.³⁶ In comparison, the surgical group had 67% return to sport at 1 month, 90% at 3 months, and 97% at 12 months.³⁶ If surgical management is chosen, there are a variety of surgical options including laparoscopy, open or mini-open repairs of the abdominal musculature/fascia or pelvic floor with and without mesh, neurolysis, and adductor release. Muschawek and Berger³⁷described a series of 129 patients that had an open-suture repair of the posterior wall of the inguinal canal with 67% of professional athletes returning to sport within 2 weeks and 83.7% of athletes returning to sport overall. The rates of return to play are consistently 80% to 100% without demonstrated superiority of one technique over another up to this point.³⁰

Continue to: PUBIC-RELATED GROIN PAIN...

Pubic-related groin pain is defined as tenderness to palpation over the pubic symphysis and adjacent bone.⁶ Osteitis pubis is a chronic overuse injury characterized by localized pain to the pubic symphysis and is believed to be caused by repetitive microtrauma from a dynamic rotation of the sacroiliac joint with suggested imbalances between the rectus abdominis and the adductor musculature.^12,38 In soccer players, the condition may be related to the constant torsional stresses of kicking, running, or twisting.¹² If performed, radiographs often show lytic areas of the pubic symphysis, widening of the symphysis, sclerosis, and cystic changes, while bone marrow edema may be present on MRI.³⁸Management consists of rest, anti-inflammatory medication, and corticosteroid injections with gentle stretching once asymptomatic.^12,39

RECTUS FEMORIS INJURIES

The most common injury to the rectus femoris is a strain as a result of an eccentric overload while a soccer player is hit trying to extend his or her leg to kick a ball.¹² In pediatric soccer athletes, an avulsion of the anterior inferior iliac spine from the direct head of the rectus femoris is the second most common avulsion injury.⁴⁰ Radiographs are diagnostic and can help determine treatment. Most avulsions are minimally displaced and can be treated conservatively, but surgical intervention should be considered for an avulsion >2 cm.¹²

PROXIMAL HAMSTRING INJURIES

Proximal hamstring injuries are important causes of acute posterior hip pain and are caused by an eccentric overload in hip flexion and knee extension.²⁵ In soccer players, the typical mechanism is that the planted leg slipping on the playing turf creates a sudden violent flexion of the hip with the knee in an extended position. While relatively uncommon, when a significant avulsion occurs in a professional athlete, surgical intervention is often necessary. In general, these injuries may involve partial or full avulsions off the ischial tuberosity or separation of the bony apophysis in pediatric athletes. A physical examination in the acute setting typically demonstrates massive posterior thigh ecchymosis, a palpable defect, and/or weakness with knee flexion. Imaging is helpful to confirm the diagnosis and evaluate for surgical repair. Radiographs may show a bony avulsion, which is more commonly seen in pediatric apophyseal avulsions. MRI can be used to differentiate a complete tear (involving all 3 tendons) vs a partial tear and evaluate for retraction of the tendon distally. Complete and partial tears of 2 tendons with retraction of >2 cm should be surgically repaired.²⁵ Partial tears without tendon retraction may be treated conservatively with rest, anti-inflammatory medication, and physical therapy and then followed later by a hamstring prevention program.²⁵ We have found that biologic augmentation with platelet-rich plasma can help accelerate healing in partial thickness injuries; however, the evidence is conflicting.

GLUTEAL INJURIES

Chronic overuse injuries of the gluteal musculature are common causes of lateral hip pain. Abductor overuse caused by weakness in the gluteus medius with a normal tensor fascia lata can cause pain with sitting and side-lying.²⁵Overuse of the gluteal muscles with muscular imbalances along with increased tension on the iliotibial band can lead to greater trochanteric pain syndrome.²⁵ A physical examination may demonstrate tenderness over the greater trochanter bursa and positive flexion, abduction, and external rotation testing.²⁵ Abductor overuse syndrome and greater trochanteric pain syndrome are best treated with anti-inflammatory medication and physical therapy to balance the core/pelvic musculature.⁴¹

PIRIFORMIS INJURIES

Piriformis syndrome is a compressive neuropathy of the sciatic nerve. The mechanism of injury in the athlete is through a minor trauma to the buttock or pelvis.^25,42,43 Presenting symptoms include pain with sitting and internal rotation of the hip.¹² Zeren and colleagues⁴² published the only study that includes 2 cases of bilateral piriformis syndrome in professional soccer players. The diagnosis was confirmed with electromyography that was negative at rest and positive when measured after running.⁴² The athletes exhausted conservative treatment with physical therapy, anti-inflammatory medications, injections, and rest and were treated with surgical decompression.⁴² Both players returned to professional soccer after 6 months and played for an average of 7 years.⁴²

Continue to: HIP-RELATED GROIN PAIN IN SOCCER ATHLETES...

HIP-RELATED GROIN PAIN IN SOCCER ATHLETES

Hip-related groin pain has garnered more attention in the last several years after being a previously underdiagnosed entity. One study found that practitioners treated groin pain in athletes for 7 months on average before recognizing that the pathology was intra-articular.⁴⁴ FAI, labral tears, and chondral injuries are the major intra-articular pathologies that cause groin pain in athletes and ultimately impaired performance.^45,46

FEMOROACETABULAR IMPINGEMENT

FAI is caused by pincer-type, cam-type, or combined-type deformities. Pincer lesions are defined as an increased acetabular overhang, while cam lesions are described as an increased bone at the femoral head/neck junction. These deformities in isolation or in combination cause decreased hip motion and increased contact pressures between the anterolateral acetabulum and femoral head-neck junction, which may ultimately lead to labral tears, chondral lesions, and osteoarthritis.⁴⁷ During hip flexion, cam deformities impact the anterolateral acetabulum, preferentially causing articular cartilage damage, while sparing the labrum.²⁵ Conversely, pincer deformities cause repetitive microtrauma to the labrum, crushing it between the acetabular rim and femoral neck with secondary damage to the articular cartilage.²⁵ Over time, the damage to the labrum and articular cartilage may lead to premature osteoarthritis, which occurs at a much younger age in the athletic population.⁴⁸

We know from previous studies that soccer athletes have a high prevalence of morphologic abnormalities of the hip, most commonly FAI. Gerhardt and colleagues⁴⁹ documented the prevalence of hip morphologic abnormalities in elite soccer players and found abnormalities in 72% of men and over 50% of women. It should be noted that this series looked at asymptomatic athletes; however, it has been shown that hip dysmorphia is a risk factor for hip and groin injuries and may provide an opportunity for injury prevention strategies.⁵⁰

Physical examination findings in FAI include decreased hip internal rotation and pain with provocative testing. Wyss and colleagues⁵¹ measured hip internal rotation in athletes with and without FAI. They found that the athletes with FAI have an average of 4° of internal rotation compared with that of the non-FAI athletes with 28°.⁵¹ A worsening internal rotation deficit has been linked to increasing severity of the deformity and when <20° was correlated with joint damage.⁵¹ Provocative testing has a high sensitivity with a recent meta-analysis demonstrating the most sensitive tests to be the anterior impingement test (flexion-adduction-internal rotation) with 94% to 99% sensitivity and the flexion-internal rotation test with 96% sensitivity.⁵² While provocative tests are sensitive, there is no current consensus on physical examination findings that are specific in the diagnosis of FAI.⁶ Diagnosis is made with both positive physical examination and radiographic morphologic findings (alpha angle >55°).³³ Advanced imaging with an MRI arthrogram can be helpful in diagnosing underlying injuries such as labral tears in athletes presenting with compatible symptoms.

Symptomatic patients are typically treated surgically through either open or arthroscopic procedures, which have favorable and comparable functional results, biomechanics, and return to sport.⁵³ In soccer players, return to sport at the professional level after arthroscopic surgery was found to be 96%.⁵⁴ Players returned to sport on average 9.2 months postoperatively and played an average of 70 games after surgery.⁵⁴

Continue to: LABRAL TEARS...

Labral tears present with groin pain, limited hip range of motion, and symptoms of catching, locking, and instability.²⁵Causes of labral tears include trauma, FAI, hip dysplasia, capsular laxity, and degeneration.⁵⁵ Labral tears rarely occur in isolation and have a high association (87%) with morphologic abnormalities of the hip, most commonly FAI and occasionally dysplasia.^56,57 Physical examination findings include positive anterior impingement tests (flexion-adduction-internal rotation) in athletes with anterior labral tears and, less commonly, positive flexion, abduction, and external rotation tests for athletes with lateral and posterolateral labral tears.⁵⁷ Radiographic imaging is used to evaluate for concurrent morphologic abnormalities of the hip, and MRI arthrogram is used to confirm the diagnosis of a labral tear with a sensitivity of 76% to 91%.⁵⁸ Initial treatment consists of conservative treatment, which includes rest, anti-inflammatory medication, activity modification, and physical therapy. In patient refractory to conservative treatment, arthroscopic surgery is effective with high rates of return to sport.⁵⁹ It is important to note that when treating labral tears surgically, any morphologic abnormality needs to be addressed to prevent recurrence of the tear.

CHONDRAL INJURIES

Focal chondral lesions in the hip are commonly found in athletes with FAI and labral tears during arthroscopic evaluation.⁶⁰ Full-thickness defects and unstable flaps in weight-bearing areas are indications for surgical intervention with microfracture.⁶⁰ There are no studies examining the efficacy of microfracture in isolation; however, Locks and colleagues⁵⁴ have demonstrated a 96% return to professional soccer after an arthroscopic treatment for FAI and found that severe chondral damage with microfracture did not lengthen the return to sport.

RELATIONSHIP BETWEEN INGUINAL-RELATED GROIN PAIN AND FEMOROACETABULAR IMPINGEMENT

The altered biomechanics and restricted range of motion in athletes with FAI cause an increase in compensatory motion at the pelvis and lumbosacral areas, which may contribute to the development of inguinal-related groin pain, bursitis, adductor, and gluteal dysfunction.²⁵ In athletes with concurrent intra-articular hip pathology and inguinal-related groin pain, treating 1 condition in isolation will result in poor results. Larson and colleagues⁶¹ found that when only inguinal-related groin pain or FAI were addressed, return to sport was only 25% and 50%, respectively, while concurrent surgical treatment resulted in a return to sport of 89%.

DISCUSSION AND FUTURE DIRECTIONS

Groin injuries in soccer players can cause significant decreases in athletic performance, result in lost playing time, and may ultimately need a surgical intervention. Efforts are underway to determine the role and efficacy of identifying high-risk athletes that may benefit from targeted prevention strategies. Wyles and colleagues⁴⁸ identified adolescent athletes with hip internal rotation of <10° and found at 5-year follow-up that 95% had abnormal MRI findings compared with 54% in the age-matched control group. Wollin and colleagues⁶² developed an in-season screening protocol using adductor strength reductions of 15%, adductor/abductor strength ratio <0.9, and hip and groin outcome scores <75 as indicators of at-risk individuals. By employing preseason and in-season screening protocols, we can identify high-risk athletes for further workup and close follow-up throughout the season. Pelvic radiographs in these high-risk athletes may help us determine the presence of abnormalities in hip morphology, which would place an athlete into a high-risk group where prevention strategies could then be employed. There are no data available to determine the most effective prevention strategy at this time. However, levels II and III evidence exists indicating that exercise programs may reduce the incidence of groin injuries.⁶³ Additional strategies, like limiting adolescent playing time similar to strategies employed in baseball pitches with pitch counts, could potentially reduce the potential for injury. Further studies on preseason screening and in-season monitoring protocols, targeted exercise therapy, early surgical intervention, and potential biologic intervention are needed to determine the most effective methods of preventing groin injuries in athletes.

The main goal of this systematic review is to present the existing evidence regarding the influence of player position on injury incidence in male soccer and to present practical considerations on each field position in relation to the injury’s risk.

METHODS

DATA SOURCES AND SELECTION CRITERIA

We searched the Medline database for key terms and their variations to identify appropriate studies on injury epidemiology in soccer and specific player position influence. The keywords included: injury epidemiology soccer [OR] injury epidemiology football; position specific injury epidemiology soccer [OR] football. We limited our search to originally published English-language research articles.

Relevant data were extracted for study characteristics to ensure the included studies met certain criteria. The inclusion criteria were prospective design with minimum 6-month observational period, exclusively male soccer players’ cohorts, reported injury incidence, and documented player position in correlation with a measure of injury risk.

As stated above, we only included studies on male soccer. We also did not consider studies limited to a single injury type, considering only studies analyzing and documenting all injuries. We did not exclude studies on youth soccer but we didn’t consider studies on ≥2 more sports or mixed male and female studies.

Data were extracted by an author (FDV) and qualitatively controlled by another one (BM). Controversy were solved through discussion or confrontation with another author (LL).

Results of the included studies are presented only qualitatively because of different methodologies we encountered in documenting the potential effects of player’s role. Some studies reported differences in injury incidence within groups, others reported the proportion of injuries for each subgroup.  

Continue to: RESULTS...

RESULTS

STUDY SELECTION

Of the 1609 potential items we found in the existing literature, 102 full-text articles were screened for eligibility. Only 11 papers met the inclusion criteria and were included in the systematic review, including 2 studies on youth soccer and 9 studies on adult soccer (Figure 1). Five of the selected studies tracked only match injuries, while the remaining 6 studies presented data on both match and training injuries. As a matter of fact, the effect of player position was not so commonly evaluated or at least reported in the existing literature. Studies’ characteristics and main findings regarding player’s position are reported in Table.

GENERAL INJURY RISK AND PLAYING POSITION

Of the 11 studies included for qualitative synthesis, 5 studies reported no significant effect of player’s position on general risk of injury,^7-11 3 studies reported a greater risk in forwards,^12-14 1 study reported a greater risk in MFs,¹⁵ 1 study reported a greater risk in forwards and central defenders,⁸ and finally 1 study reported a significant lower risk in GKs.¹⁶ Additionally, 2 more studies reported GKs to be at the lowest injury risk,^12,13 another study reported GKs to have lost the lower number of matches,⁸ 1 study didn’t consider the GK position in the analysis due to the low number of injuries,¹⁷ limiting the analysis on the outfield positions.

Out of the 5 studies reporting no significant effect of playing position on injury risk, 1 study found a tendency to more injuries in forward players,¹⁰ a second study found a tendency for higher injury risk in midfielders,¹⁸ and a third study found a tendency for higher risk in defenders.¹⁷ Considering only the 5 studies reporting data on match injuries, 3 reported a higher risk in forwards,^12-14 while a fourth one reported a tendency for increased risk in forwards¹⁰ even if not statistically significant. On the other hand, evaluating the 6 studies reporting data on match and training injuries, most of the studies, 4 out of 6, reported no effect of playing position.^17-20 The main findings of the studies are also expressed graphically in Figures 2A, 2B.

DISCUSSION

The main finding of this study is that there is substantially no agreement regarding the effect of player position on general injury risk in male soccer.

First, we must underline that not many studies have evaluated prospectively the influence of player’s position on injury risk. Of the 11 selected studies, 5 (5/11) reported no significant effect of playing position,^{7,10,17,18,20} while the remaining studies (6/11)^8,12-16 reported a significant effect of player position on the risk of injury, with various results depending on the single study. It should be noted that the 2 studies with the longest observational period (15 consecutive seasons)^16,19 did not report any difference in injury risk considering only the outfield playing positions.  

Continue to: We will now review the findings...

We will now review the findings of our systematic review based on player position. One of the more consistent trends that we found is the possible occurrence of different injury epidemiology in GKs compared to outfield players. One study reported a significant lower incidence of match injuries for GKs, 12.9 injuries per 1000 game hours vs 22.6 injuries per 1000 game hours of outfield positions.¹⁶ This result is remarkable, even considering the very long observational period (15 seasons). Other 2 studies, not reporting position specific injury incidence (but proportion of injuries) also agreed on the topic.^12,13 On the other hand, Morgan and Oberlander⁹ reported no differences between GKs and other positions. Anecdotally, unpublished Major League Soccer data regarding the most recent seasons seems to support these findings with GKs sustaining the lower proportion of injuries. By a physiological point of view, somatotype and body composition have been reported to differ between GKs and the other playing positions in young male soccer players.²¹ The uniqueness of the GK somatotype and role may reflect on a predisposition to a different pattern of injuries. Ekstrand and colleagues²² reported that GKs have a higher incidence of upper extremity fractures, the same group demonstrated a possible tendency for more head and neck injuries⁹ and a lower risk of medial collateral ligament injuries.²³ On the other hand, GKs seems to be at lower injury risk for the playing pattern differences with outfield players. The reduced distance GKs cover during the match, as well as less direct contacts with opponents, may be factors that potentially explain this finding.

In relation to forwards, 4 studies interestingly stated that forwards were at increased risk of injury,^12-14 although 1 report had similar risk of injury with forwards and defenders.⁸ Most of the studies only on match injuries reported some association between forward position and injury risk (Figures 2A, 2B), so attackers may be at higher risk of match injuries when compared to the other playing positions. There are different possible explanations for this finding. First, it is demonstrated that the clear majority of soccer incidents happen in the mid-defensive zone and in the score-box,²⁴ 2 typical attackers’ zones, where most of duels and tackles may happen. So, forwards may be more prone to match injuries because of the intensity of match play in their typical playing zones. Also, fast kicking and acceleration/deceleration activities of the attackers may predispose for thigh muscle injuries, accounting up to 25% of the total lay off time in professional soccer.²⁵ However, these considerations are still yet to be proven.

When considering defenders, 1 report indicated defenders (and forwards) to be at potential greater risk of injury,⁸which is similar to the report from Shalaj and colleagues,¹⁷ although it did not report a statistically significant result. A direct playing style, with defenders and strikers being more involved in the game can potentially explain this finding. However, the specific epidemiology of defenders may be more complicated. Defenders may be predisposed to knee injuries, such as injury to the anterior cruciate ligament (ACL). In fact, Walden and colleagues,¹¹ in a video-analysis study, reported that the 77% of ACL injuries happened in defending situations. In addition, Brophy and colleagues,⁶ in another video-analysis study, reported a 73% of ACL injuries happened while defending. A likely explanation is the nature of the defender’s role in soccer, reactive to the attacking team actions. Many times, defenders try high risk maneuvers while tackling the opponent, with minimal motor planning time and consciousness. This is well described by Walden and colleagues,¹¹ with the pressing mechanism ACL injury, when the injured player is pressing the opponent in the attempt to get the ball but eventually falls into a high-risk position.

When considering MFs, Deehan and colleagues¹⁵ found a significant higher risk in MFs in youth soccer. This result is partially according to Morgan and Oberlander¹⁸ who reported a non-statistically significant greater injury incidence in MFs. MFs are generally the players that cover more distance during a soccer match and it is logical to think that they would be predisposed to a large volume of acceleration/deceleration activities,¹⁹ potentially relating to injury risk, especially to muscles injuries. A previous study on thigh muscle injuries in youth soccer reporting higher injury risk in MFs, followed by forwards.¹⁹ Consistent with these results, another study on a mixed male and female cohort on high school soccer revealed more injuries in MFs, followed by forwards^.26

Continue to: The results of this systematic review...

The results of this systematic review reveal mixed reports on injury risk in relation to playing position, the more consistent results through studies was that GKs may be at lower injury risk compared to the outfield players, even if there wasn’t complete agreement. One should note that in modern soccer the specific role of any player at 1 position may not be entirely consistent with another player in the same position. Within the same “position group”, there may also be players with completely different qualitative playing demands (eg, wing defender and central defender). So, even with the strongest study design, it may be difficult to give a simple and clear message about playing position and injury risk due to the variability of the playing styles and players at each position.

This study has several limitations and the results must be considered and interpreted with caution. First, we limited our search to male soccer, so the results may not be applicable to female soccer. Secondly, the interpretation of study findings wasn’t easy because of the different report modalities of the different papers included in the systematic review. Finally, we included reports from a total of a 23-year time span and from different countries and continents. The game may have evolved through years and there may be differences in the style of playing within countries that potentially could interfere with injury risk.

However, this is the first paper systematically evaluating the existing literature on position specific injury risk in male soccer players. Future studies, with prospective design and a consistent method to evaluate the player position as a potential factor related to injury risk, are needed. Match and training injuries should be evaluated separately as playing position may be more related to match injury risk.

CONCLUSION

There is no agreement in the existing literature regarding weather or not player position influence the general injury risk in male soccer. The GKs may have a lower risk of injury if compared to outfield players.

The main goal of this systematic review is to present the existing evidence regarding the influence of player position on injury incidence in male soccer and to present practical considerations on each field position in relation to the injury’s risk.

METHODS

DATA SOURCES AND SELECTION CRITERIA

We searched the Medline database for key terms and their variations to identify appropriate studies on injury epidemiology in soccer and specific player position influence. The keywords included: injury epidemiology soccer [OR] injury epidemiology football; position specific injury epidemiology soccer [OR] football. We limited our search to originally published English-language research articles.

Relevant data were extracted for study characteristics to ensure the included studies met certain criteria. The inclusion criteria were prospective design with minimum 6-month observational period, exclusively male soccer players’ cohorts, reported injury incidence, and documented player position in correlation with a measure of injury risk.

As stated above, we only included studies on male soccer. We also did not consider studies limited to a single injury type, considering only studies analyzing and documenting all injuries. We did not exclude studies on youth soccer but we didn’t consider studies on ≥2 more sports or mixed male and female studies.

Data were extracted by an author (FDV) and qualitatively controlled by another one (BM). Controversy were solved through discussion or confrontation with another author (LL).

Results of the included studies are presented only qualitatively because of different methodologies we encountered in documenting the potential effects of player’s role. Some studies reported differences in injury incidence within groups, others reported the proportion of injuries for each subgroup.  

Continue to: RESULTS...

RESULTS

STUDY SELECTION

Of the 1609 potential items we found in the existing literature, 102 full-text articles were screened for eligibility. Only 11 papers met the inclusion criteria and were included in the systematic review, including 2 studies on youth soccer and 9 studies on adult soccer (Figure 1). Five of the selected studies tracked only match injuries, while the remaining 6 studies presented data on both match and training injuries. As a matter of fact, the effect of player position was not so commonly evaluated or at least reported in the existing literature. Studies’ characteristics and main findings regarding player’s position are reported in Table.

GENERAL INJURY RISK AND PLAYING POSITION

Of the 11 studies included for qualitative synthesis, 5 studies reported no significant effect of player’s position on general risk of injury,^7-11 3 studies reported a greater risk in forwards,^12-14 1 study reported a greater risk in MFs,¹⁵ 1 study reported a greater risk in forwards and central defenders,⁸ and finally 1 study reported a significant lower risk in GKs.¹⁶ Additionally, 2 more studies reported GKs to be at the lowest injury risk,^12,13 another study reported GKs to have lost the lower number of matches,⁸ 1 study didn’t consider the GK position in the analysis due to the low number of injuries,¹⁷ limiting the analysis on the outfield positions.

Out of the 5 studies reporting no significant effect of playing position on injury risk, 1 study found a tendency to more injuries in forward players,¹⁰ a second study found a tendency for higher injury risk in midfielders,¹⁸ and a third study found a tendency for higher risk in defenders.¹⁷ Considering only the 5 studies reporting data on match injuries, 3 reported a higher risk in forwards,^12-14 while a fourth one reported a tendency for increased risk in forwards¹⁰ even if not statistically significant. On the other hand, evaluating the 6 studies reporting data on match and training injuries, most of the studies, 4 out of 6, reported no effect of playing position.^17-20 The main findings of the studies are also expressed graphically in Figures 2A, 2B.

DISCUSSION

The main finding of this study is that there is substantially no agreement regarding the effect of player position on general injury risk in male soccer.

First, we must underline that not many studies have evaluated prospectively the influence of player’s position on injury risk. Of the 11 selected studies, 5 (5/11) reported no significant effect of playing position,^{7,10,17,18,20} while the remaining studies (6/11)^8,12-16 reported a significant effect of player position on the risk of injury, with various results depending on the single study. It should be noted that the 2 studies with the longest observational period (15 consecutive seasons)^16,19 did not report any difference in injury risk considering only the outfield playing positions.  

Continue to: We will now review the findings...

We will now review the findings of our systematic review based on player position. One of the more consistent trends that we found is the possible occurrence of different injury epidemiology in GKs compared to outfield players. One study reported a significant lower incidence of match injuries for GKs, 12.9 injuries per 1000 game hours vs 22.6 injuries per 1000 game hours of outfield positions.¹⁶ This result is remarkable, even considering the very long observational period (15 seasons). Other 2 studies, not reporting position specific injury incidence (but proportion of injuries) also agreed on the topic.^12,13 On the other hand, Morgan and Oberlander⁹ reported no differences between GKs and other positions. Anecdotally, unpublished Major League Soccer data regarding the most recent seasons seems to support these findings with GKs sustaining the lower proportion of injuries. By a physiological point of view, somatotype and body composition have been reported to differ between GKs and the other playing positions in young male soccer players.²¹ The uniqueness of the GK somatotype and role may reflect on a predisposition to a different pattern of injuries. Ekstrand and colleagues²² reported that GKs have a higher incidence of upper extremity fractures, the same group demonstrated a possible tendency for more head and neck injuries⁹ and a lower risk of medial collateral ligament injuries.²³ On the other hand, GKs seems to be at lower injury risk for the playing pattern differences with outfield players. The reduced distance GKs cover during the match, as well as less direct contacts with opponents, may be factors that potentially explain this finding.

In relation to forwards, 4 studies interestingly stated that forwards were at increased risk of injury,^12-14 although 1 report had similar risk of injury with forwards and defenders.⁸ Most of the studies only on match injuries reported some association between forward position and injury risk (Figures 2A, 2B), so attackers may be at higher risk of match injuries when compared to the other playing positions. There are different possible explanations for this finding. First, it is demonstrated that the clear majority of soccer incidents happen in the mid-defensive zone and in the score-box,²⁴ 2 typical attackers’ zones, where most of duels and tackles may happen. So, forwards may be more prone to match injuries because of the intensity of match play in their typical playing zones. Also, fast kicking and acceleration/deceleration activities of the attackers may predispose for thigh muscle injuries, accounting up to 25% of the total lay off time in professional soccer.²⁵ However, these considerations are still yet to be proven.

When considering defenders, 1 report indicated defenders (and forwards) to be at potential greater risk of injury,⁸which is similar to the report from Shalaj and colleagues,¹⁷ although it did not report a statistically significant result. A direct playing style, with defenders and strikers being more involved in the game can potentially explain this finding. However, the specific epidemiology of defenders may be more complicated. Defenders may be predisposed to knee injuries, such as injury to the anterior cruciate ligament (ACL). In fact, Walden and colleagues,¹¹ in a video-analysis study, reported that the 77% of ACL injuries happened in defending situations. In addition, Brophy and colleagues,⁶ in another video-analysis study, reported a 73% of ACL injuries happened while defending. A likely explanation is the nature of the defender’s role in soccer, reactive to the attacking team actions. Many times, defenders try high risk maneuvers while tackling the opponent, with minimal motor planning time and consciousness. This is well described by Walden and colleagues,¹¹ with the pressing mechanism ACL injury, when the injured player is pressing the opponent in the attempt to get the ball but eventually falls into a high-risk position.

When considering MFs, Deehan and colleagues¹⁵ found a significant higher risk in MFs in youth soccer. This result is partially according to Morgan and Oberlander¹⁸ who reported a non-statistically significant greater injury incidence in MFs. MFs are generally the players that cover more distance during a soccer match and it is logical to think that they would be predisposed to a large volume of acceleration/deceleration activities,¹⁹ potentially relating to injury risk, especially to muscles injuries. A previous study on thigh muscle injuries in youth soccer reporting higher injury risk in MFs, followed by forwards.¹⁹ Consistent with these results, another study on a mixed male and female cohort on high school soccer revealed more injuries in MFs, followed by forwards^.26

Continue to: The results of this systematic review...

The results of this systematic review reveal mixed reports on injury risk in relation to playing position, the more consistent results through studies was that GKs may be at lower injury risk compared to the outfield players, even if there wasn’t complete agreement. One should note that in modern soccer the specific role of any player at 1 position may not be entirely consistent with another player in the same position. Within the same “position group”, there may also be players with completely different qualitative playing demands (eg, wing defender and central defender). So, even with the strongest study design, it may be difficult to give a simple and clear message about playing position and injury risk due to the variability of the playing styles and players at each position.

This study has several limitations and the results must be considered and interpreted with caution. First, we limited our search to male soccer, so the results may not be applicable to female soccer. Secondly, the interpretation of study findings wasn’t easy because of the different report modalities of the different papers included in the systematic review. Finally, we included reports from a total of a 23-year time span and from different countries and continents. The game may have evolved through years and there may be differences in the style of playing within countries that potentially could interfere with injury risk.

However, this is the first paper systematically evaluating the existing literature on position specific injury risk in male soccer players. Future studies, with prospective design and a consistent method to evaluate the player position as a potential factor related to injury risk, are needed. Match and training injuries should be evaluated separately as playing position may be more related to match injury risk.

CONCLUSION

There is no agreement in the existing literature regarding weather or not player position influence the general injury risk in male soccer. The GKs may have a lower risk of injury if compared to outfield players.

The main goal of this systematic review is to present the existing evidence regarding the influence of player position on injury incidence in male soccer and to present practical considerations on each field position in relation to the injury’s risk.

METHODS

DATA SOURCES AND SELECTION CRITERIA

We searched the Medline database for key terms and their variations to identify appropriate studies on injury epidemiology in soccer and specific player position influence. The keywords included: injury epidemiology soccer [OR] injury epidemiology football; position specific injury epidemiology soccer [OR] football. We limited our search to originally published English-language research articles.

Relevant data were extracted for study characteristics to ensure the included studies met certain criteria. The inclusion criteria were prospective design with minimum 6-month observational period, exclusively male soccer players’ cohorts, reported injury incidence, and documented player position in correlation with a measure of injury risk.

As stated above, we only included studies on male soccer. We also did not consider studies limited to a single injury type, considering only studies analyzing and documenting all injuries. We did not exclude studies on youth soccer but we didn’t consider studies on ≥2 more sports or mixed male and female studies.

Data were extracted by an author (FDV) and qualitatively controlled by another one (BM). Controversy were solved through discussion or confrontation with another author (LL).

Results of the included studies are presented only qualitatively because of different methodologies we encountered in documenting the potential effects of player’s role. Some studies reported differences in injury incidence within groups, others reported the proportion of injuries for each subgroup.  

Continue to: RESULTS...

RESULTS

STUDY SELECTION

Of the 1609 potential items we found in the existing literature, 102 full-text articles were screened for eligibility. Only 11 papers met the inclusion criteria and were included in the systematic review, including 2 studies on youth soccer and 9 studies on adult soccer (Figure 1). Five of the selected studies tracked only match injuries, while the remaining 6 studies presented data on both match and training injuries. As a matter of fact, the effect of player position was not so commonly evaluated or at least reported in the existing literature. Studies’ characteristics and main findings regarding player’s position are reported in Table.

GENERAL INJURY RISK AND PLAYING POSITION

Of the 11 studies included for qualitative synthesis, 5 studies reported no significant effect of player’s position on general risk of injury,^7-11 3 studies reported a greater risk in forwards,^12-14 1 study reported a greater risk in MFs,¹⁵ 1 study reported a greater risk in forwards and central defenders,⁸ and finally 1 study reported a significant lower risk in GKs.¹⁶ Additionally, 2 more studies reported GKs to be at the lowest injury risk,^12,13 another study reported GKs to have lost the lower number of matches,⁸ 1 study didn’t consider the GK position in the analysis due to the low number of injuries,¹⁷ limiting the analysis on the outfield positions.

Out of the 5 studies reporting no significant effect of playing position on injury risk, 1 study found a tendency to more injuries in forward players,¹⁰ a second study found a tendency for higher injury risk in midfielders,¹⁸ and a third study found a tendency for higher risk in defenders.¹⁷ Considering only the 5 studies reporting data on match injuries, 3 reported a higher risk in forwards,^12-14 while a fourth one reported a tendency for increased risk in forwards¹⁰ even if not statistically significant. On the other hand, evaluating the 6 studies reporting data on match and training injuries, most of the studies, 4 out of 6, reported no effect of playing position.^17-20 The main findings of the studies are also expressed graphically in Figures 2A, 2B.

DISCUSSION

The main finding of this study is that there is substantially no agreement regarding the effect of player position on general injury risk in male soccer.

First, we must underline that not many studies have evaluated prospectively the influence of player’s position on injury risk. Of the 11 selected studies, 5 (5/11) reported no significant effect of playing position,^{7,10,17,18,20} while the remaining studies (6/11)^8,12-16 reported a significant effect of player position on the risk of injury, with various results depending on the single study. It should be noted that the 2 studies with the longest observational period (15 consecutive seasons)^16,19 did not report any difference in injury risk considering only the outfield playing positions.  

Continue to: We will now review the findings...

We will now review the findings of our systematic review based on player position. One of the more consistent trends that we found is the possible occurrence of different injury epidemiology in GKs compared to outfield players. One study reported a significant lower incidence of match injuries for GKs, 12.9 injuries per 1000 game hours vs 22.6 injuries per 1000 game hours of outfield positions.¹⁶ This result is remarkable, even considering the very long observational period (15 seasons). Other 2 studies, not reporting position specific injury incidence (but proportion of injuries) also agreed on the topic.^12,13 On the other hand, Morgan and Oberlander⁹ reported no differences between GKs and other positions. Anecdotally, unpublished Major League Soccer data regarding the most recent seasons seems to support these findings with GKs sustaining the lower proportion of injuries. By a physiological point of view, somatotype and body composition have been reported to differ between GKs and the other playing positions in young male soccer players.²¹ The uniqueness of the GK somatotype and role may reflect on a predisposition to a different pattern of injuries. Ekstrand and colleagues²² reported that GKs have a higher incidence of upper extremity fractures, the same group demonstrated a possible tendency for more head and neck injuries⁹ and a lower risk of medial collateral ligament injuries.²³ On the other hand, GKs seems to be at lower injury risk for the playing pattern differences with outfield players. The reduced distance GKs cover during the match, as well as less direct contacts with opponents, may be factors that potentially explain this finding.

In relation to forwards, 4 studies interestingly stated that forwards were at increased risk of injury,^12-14 although 1 report had similar risk of injury with forwards and defenders.⁸ Most of the studies only on match injuries reported some association between forward position and injury risk (Figures 2A, 2B), so attackers may be at higher risk of match injuries when compared to the other playing positions. There are different possible explanations for this finding. First, it is demonstrated that the clear majority of soccer incidents happen in the mid-defensive zone and in the score-box,²⁴ 2 typical attackers’ zones, where most of duels and tackles may happen. So, forwards may be more prone to match injuries because of the intensity of match play in their typical playing zones. Also, fast kicking and acceleration/deceleration activities of the attackers may predispose for thigh muscle injuries, accounting up to 25% of the total lay off time in professional soccer.²⁵ However, these considerations are still yet to be proven.

When considering defenders, 1 report indicated defenders (and forwards) to be at potential greater risk of injury,⁸which is similar to the report from Shalaj and colleagues,¹⁷ although it did not report a statistically significant result. A direct playing style, with defenders and strikers being more involved in the game can potentially explain this finding. However, the specific epidemiology of defenders may be more complicated. Defenders may be predisposed to knee injuries, such as injury to the anterior cruciate ligament (ACL). In fact, Walden and colleagues,¹¹ in a video-analysis study, reported that the 77% of ACL injuries happened in defending situations. In addition, Brophy and colleagues,⁶ in another video-analysis study, reported a 73% of ACL injuries happened while defending. A likely explanation is the nature of the defender’s role in soccer, reactive to the attacking team actions. Many times, defenders try high risk maneuvers while tackling the opponent, with minimal motor planning time and consciousness. This is well described by Walden and colleagues,¹¹ with the pressing mechanism ACL injury, when the injured player is pressing the opponent in the attempt to get the ball but eventually falls into a high-risk position.

When considering MFs, Deehan and colleagues¹⁵ found a significant higher risk in MFs in youth soccer. This result is partially according to Morgan and Oberlander¹⁸ who reported a non-statistically significant greater injury incidence in MFs. MFs are generally the players that cover more distance during a soccer match and it is logical to think that they would be predisposed to a large volume of acceleration/deceleration activities,¹⁹ potentially relating to injury risk, especially to muscles injuries. A previous study on thigh muscle injuries in youth soccer reporting higher injury risk in MFs, followed by forwards.¹⁹ Consistent with these results, another study on a mixed male and female cohort on high school soccer revealed more injuries in MFs, followed by forwards^.26

Continue to: The results of this systematic review...

The results of this systematic review reveal mixed reports on injury risk in relation to playing position, the more consistent results through studies was that GKs may be at lower injury risk compared to the outfield players, even if there wasn’t complete agreement. One should note that in modern soccer the specific role of any player at 1 position may not be entirely consistent with another player in the same position. Within the same “position group”, there may also be players with completely different qualitative playing demands (eg, wing defender and central defender). So, even with the strongest study design, it may be difficult to give a simple and clear message about playing position and injury risk due to the variability of the playing styles and players at each position.

This study has several limitations and the results must be considered and interpreted with caution. First, we limited our search to male soccer, so the results may not be applicable to female soccer. Secondly, the interpretation of study findings wasn’t easy because of the different report modalities of the different papers included in the systematic review. Finally, we included reports from a total of a 23-year time span and from different countries and continents. The game may have evolved through years and there may be differences in the style of playing within countries that potentially could interfere with injury risk.

However, this is the first paper systematically evaluating the existing literature on position specific injury risk in male soccer players. Future studies, with prospective design and a consistent method to evaluate the player position as a potential factor related to injury risk, are needed. Match and training injuries should be evaluated separately as playing position may be more related to match injury risk.

CONCLUSION

There is no agreement in the existing literature regarding weather or not player position influence the general injury risk in male soccer. The GKs may have a lower risk of injury if compared to outfield players.

Unsurprisingly, upper extremity injuries are reported to be up to 5 times more common in goalkeepers than in outfield players,^1,2 reaching a high rate of up to 18% of all injuries among professional goalkeepers. The usage of upper extremities to stop the ball and repeated reaching to the ball and landing on the ground with changing upper extremity positions are some of the contributors to the increased upper extremity injury risk in goalkeepers.

Following 57 male professional European soccer teams from 16 countries between the years 2001 and 2011, Ekstrand and colleagues¹ showed that 90% of upper extremity injuries are traumatic, and only 10% are related to overuse. They also reported that the most common upper extremity injury location is the shoulder/clavicle (56%), followed by the hand/finger/thumb (24%), elbow (10%), wrist (5%), forearm (4%), and upper arm (1%). Specifically, the 6 most common injuries are acromioclavicular joint (ACJ) sprain (13%), shoulder dislocation (12%), hand metacarpal fracture (8%), shoulder rotator cuff tendinopathy (6%), hand phalanx fracture (6%), and shoulder ACJ dislocation (5%). 

This article will discuss common upper extremity injuries observed in soccer players, focusing on proper diagnosis and optimal management.

Continue to: THE SHOULDER...

THE SHOULDER

The majority of upper extremity injuries in professional soccer players are shoulder injuries.^1,2,4 Almost a third of these injuries (28%) are considered severe, preventing participation in training and matches for 28 days or more.⁶Ekstrand and colleagues¹ reported that shoulder dislocation represents the most severe upper extremity injury with a mean of 41 days of absence from soccer. When considering the position of the player, they further demonstrated that absence from full training and matches is twice as long for goalkeepers as for outfield players, which reflects the importance of shoulder function for goalkeepers.

In terms of the mechanism of shoulder instability injuries in soccer players, more than half (56%) of these injuries occur with a high-energy mechanism in the recognized position of combined humeral abduction and external rotation against a force of external rotation and horizontal extension.³ However, almost a quarter (24%) occur with a mechanism of varied upper extremity position and low-energy trauma, and 20% of injuries are either a low energy injury with little or no contact or gradual onset. These unique characteristics of shoulder instability injuries in soccer players should be accounted for during training and may imply that current training programs are suboptimal for the prevention of upper extremity injuries and shoulder injuries. Ejnisman and colleagues² reported on the development of a Fédération Internationale de Football Association (FIFA) 11+ shoulder injury prevention program for soccer goalkeepers as one of the ways to promote training programs that address the risk of shoulder injuries.

Reporting on the management of severe shoulder injuries requiring surgery in 25 professional soccer players in England, between 2007 and 2011, Hart and Funk³ found that the majority of subjects (88%) reported a dislocation as a feature of their presentation. Twenty-one (84%) subjects were diagnosed with labral injuries, of which 7 had an associated Hill-Sachs lesion. Two (8%) subjects were diagnosed with rotator cuff tears requiring repair, and 2 (8%) subjects had a combination of rotator cuff and labral injury repair. All patients underwent arthroscopic repair, except for 5 who had a Latarjet coracoid transfer. Post-surgery, all players were able to return to unrestricted participation in soccer at a mean of 11.4 weeks, with no significant difference between goalkeepers and outfield players and no recurrences at a mean of 91 weeks’ follow-up. 

Up to one-third of shoulder instability injuries in soccer players are reported to be recurrences,^1,3 which emphasizes the need to carefully assess soccer players before clearing them to return to play. These data raise the controversy over the treatment of first time shoulder dislocators and may support early surgical intervention.^7-9 In terms of the preferred surgical intervention in these cases, Balg and Boileau¹⁰ suggested a simple scoring system based on factors derived from a preoperative questionnaire, physical examination, and anteroposterior radiographs to help distinguish between patients who will benefit from an arthroscopic anterior stabilization using suture anchors and those who will require a bony procedure (open or arthroscopic). Cerciello and colleagues¹¹ reported excellent results for bony stabilization (modified Latarjet) in a population of 26 soccer players (28 shoulders) affected by chronic anterior instability. Only 1 player did not return to soccer, and 18 players (20 shoulders, 71%) returned to the same level. One re-dislocation was noted in a goalkeeper 74 months after surgery.

An injury to the ACJ has been previously reported to be the most prevalent type of shoulder injury in contact sports.¹²In soccer, injury to the ACJ is responsible for 18% of upper extremity injuries, and the majority (72%) are sprains.¹Interestingly, but unsurprisingly, implications of such an injury differ significantly between goalkeepers and outfield players with up to 3 times longer required absence periods for goalkeepers vs outfield players sustaining the same injury.

ACJ injury is commonly the result of a direct fall on the shoulder with the arm adducted or extended. Six grades of ACJ injuries have been described and distinguished by the injured anatomical structure (acromioclavicular ligaments and coracoclavicular ligaments) and the direction and magnitude of clavicular dislocation.^13,14 Presentation will usually include anterior shoulder pain, a noticeable swelling or change in morphology of the lateral end of the clavicle (mainly in dislocation types), and sharp pain provoked by palpation of the ACJ. Radiographic imaging will confirm the diagnosis and help with identifying the specific grade/type of injury.

Decision making and management of acute ACJ injury should be based on the type/grade of injury. Nonoperative treatment is recommended for types I and II, and most athletes have a successful outcome with a full return to play.¹²Types IV, V, and VI are treated early with operative intervention, mostly due to the morbidity associated with prolonged dislocation of the joint and subsequent soft tissue damage.¹² Treatment of type III injury remains controversial. Pereira-Graterol and colleagues¹⁵ reported the effectiveness of clavicular hook plate (DePuy Synthes) in the surgical stabilization of grade III ACJ dislocation in 11 professional soccer players. At a mean follow-up of 4 years, they showed excellent functional results with full shoulder range of motion at 5 weeks and latest return to soccer at 6 months. The hook plate was removed after 16 weeks in 10 patients in whom no apparent complication was observed.

Continue to: THE ELBOW...

THE ELBOW

Ekstrand and colleagues¹ reported that 10% of all upper extremity injuries in professional soccer players are elbow injuries, of which only 19% are considered severe injuries that require more than 28 days of absence from playing soccer. The most common elbow injuries in their cohort were elbow medial collateral ligament (MCL) sprain and olecranon bursitis.

Elbow MCL is the primary constraint of the elbow joint to valgus stress, and MCL sprain occurs when the elbow is subjected to a valgus, or laterally directed force, which distracts the medial side of the elbow, exceeding the tensile properties of the MCL.¹⁶ A thorough physical examination that includes valgus stress tests through the arc of elbow flexion and extension to elicit a possible subjective feeling of apprehension, instability, or localized pain is essential for optimal evaluation and treatment.^16,17 Imaging studies (X-ray and stress X-rays, dynamic ultrasound, computed tomography [CT], magnetic resonance imaging [MRI], and MR arthrography) have a role in further establishing the diagnosis and identifying possible additional associated injuries.¹⁶ The treatment plan should be specifically tailored to the individual athlete, depending on his demands and the degree of MCL injury. In soccer, which is a non-throwing shoulder sport, nonoperative treatment should be the preferred initial treatment in most cases. Ekstrand and colleagues¹ showed that this injury requires a mean of 4 days of absence from soccer for outfield players and a mean of 21 days of absence from soccer for goalkeepers, thereby indicating more severe sprains and cautious return to soccer in goalkeepers. Athletes who fail nonoperative treatment are candidates for MCL reconstruction.¹⁶

The olecranon bursa is a synovium-lined sac that facilitates gliding between the olecranon and overlying skin. Olecranon bursitis is characterized by accumulation of fluid in the bursa with or without inflammation. The fluid can be serous, sanguineous, or purulent depending on the etiology.¹⁸ In soccer, traumatic etiology is common, but infection secondary to cuts or scratches of the skin around the elbow or previous therapeutic injections around the elbow should always be ruled out. Local pain, swelling, warmth, and redness are usually the presenting symptoms. Aseptic olecranon bursitis may be managed non-surgically with ‘‘benign neglect’’ and avoidance of pressure to the area, non-steroidal anti-inflammatory drugs, needle aspiration, corticosteroid injection, compression dressings, and/or padded splinting; whereas acute septic bursitis requires needle aspiration for diagnosis, appropriate oral or intravenous antibiotics directed toward the offending organism, and, when clinically indicated, surgical evacuation/excision of the bursa.¹⁸ When treating this condition with cortisone injection, possible complications, such as skin atrophy, secondary infection, and chronic local pain, have been reported and should be considered.¹⁹

Severe elbow injuries in professional athletes in general,^20-22 and soccer players specifically, are elbow subluxations/dislocations and elbow fracture. The mechanism of injury is usually contact injury with an opponent player or a fall on the palm with the arm extended. Posterolateral is the most common type of elbow dislocation. Elbow dislocations are further classified into simple (no associated fractures) and complex (associated with fractures) categories.²² Simple dislocations are usually treated with early mobilization after closed reduction; it is associated with a low risk for re-dislocation and with generally good results. The complex type of elbow fracture dislocation is more difficult to treat, has higher complication and re-dislocation rates, and requires operative treatment in most cases compared with simple dislocation.²² The “terrible triad” of the elbow (posterior elbow dislocation, radial head fracture, and coronoid fracture) represents a specific complex elbow dislocation scenario that is difficult to manage because of conflicting aims of ensuring elbow stability while maintaining early range of motion.²²

Isolated fracture around the elbow should be treated based on known principles of fracture management: mechanism of injury, fracture patterns, fracture displacement, intra-articular involvement, soft tissue condition, and associated injuries.

Continue to: THE WRIST...

THE WRIST

Ekstrand and colleagues¹ reported that 5% of all upper extremity injuries in their cohort of professional soccer players are wrist injuries, of which, only 2% are considered severe injuries that require >28 days of absence from playing soccer. The more common wrist injuries in soccer, which is considered a high-impact sport, are fractures (distal radius, scaphoid, capitate), and less reported injuries are dislocations (lunate, perilunate) and ligamentous injuries or tears (scapholunate ligament).²³

Distal radius fractures in high-impact sports, like soccer, usually occur as a result of a fall on an out-stretched hand and will usually be more comminuted, displaced, and intra-articular compared with low-impact sports.²³ All these aforementioned characteristics usually indicate surgical management of open reduction and internal fixation, which will allow for rapid start of rehabilitation and return to play.

Scaphoid fracture is the most common carpal bone fracture and presents unique challenges in terms of diagnosis and optimal treatment²⁴ in professional athletes. A typical injury scenario would be a player falling on an outstretched hand and sustaining a scaphoid fracture during a match or training session. The player may acknowledge some wrist pain but will often continue to play with minimal or no limitation. As wrist pain and swelling become more evident after the match/training session, the player will seek medical evaluation.²⁴ A complete wrist and upper extremity examination should be performed in addition to a specific assessment, which includes palpation of the distal scaphoid pole at the distal wrist flexion crease, palpation of the scaphoid waist through the wrist snuff box, and palpation dorsally just distal to the Lister tubercle at the scapholunate joint. Any wrist injury that results in decreased range of motion, snuff box swelling, and scaphoid tenderness should be further evaluated with imaging. Plain radiographs with special scaphoid views are the initial preferred imaging studies, but occult fracture will require an additional study such as a bone scan, CT, or MRI. Several studies have validated the benefit of MRI and the fact that it may outweigh the costs associated with lost productivity from unnecessary cast immobilization, especially in elite athletes.^23-25Casting the patient with a nondisplaced scaphoid waist fracture has been the traditional treatment; however, stiffness, weakness, and deconditioning that can occur with long-term casting required for scaphoid fractures are significant impairments for the professional athlete and usually end the player’s season. Surgical treatment, which was traditionally indicated for displaced or proximal pole fractures, is currently also considered for non-displaced scaphoid waist fractures in professional athletes. This treatment allows for a rapid return to the rehabilitation of the extremity and possible early return to professional sport. In view of the known complications (eg, malunion, nonunion, and avascular necrosis), return to soccer can be considered when imaging confirms advanced healing, which some consider as at least 50% of bone fracture bridging on CT scan, no pain, excellent motion, and at least 80% of normal grip strength.²⁴ Outfield players can return to play with a protective cast or brace until full healing is observed on imaging.

Continue to: THE HAND/FINGERS/THUMB...

THE HAND/FINGERS/THUMB

Almost a quarter of upper extremity injuries in professional soccer players were reported to involve the hand, fingers, and thumb. A quarter of them were classified as severe injuries requiring >28 days of absence from playing soccer.¹Specifically, hand metacarpal and phalanx fractures are the most common reported injuries in sports in general,²⁶ and in soccer,¹ and account for 14% of all upper extremity injuries¹ in professional soccer players. Goalkeepers require a functional hand to play, whereas an outfielder can play with protection on the injured area; thus, the period of absence from soccer in these injuries is significantly different between goalkeepers and outfielders with more than 4 times longer absence from soccer for a goalkeeper compared with an outfielder. The fifth ray has been shown to be the most frequently fractured ray in the hand in soccer with 51.7% of all hand fractures reported.²⁶ The common mechanism is a full hit on the hand, and a direct hit from the ball is another possible mechanism in goalkeepers.

In general, the diagnosis of hand injuries requires evaluation of the mechanism of injury and injury symptoms, proper and comprehensive physical examination of the whole extremity, and prompt imaging. In most cases, plain radiographs in several projections will suffice for the diagnosis of obvious fractures, but CT scan is an additional modality that allows for improved appreciation of occult or complex and comminuted fracture patterns. MRI or ultrasound can be used additionally whenever associated soft tissue injury is suspected. Optimal management of the hand is based on the specific characteristics of the fractures, which include location, direction of the fracture line, presence of comminution, displacement, articular involvement, and associated soft tissue injury. Nondisplaced extra-articular fractures often can be treated with buddy taping or splinting, whereas intra-articular fractures often require surgical treatment. Displaced fractures of the hand have a tendency to angulate volarly because of attachments of the interosseous muscles. Marginal fractures or avulsion fractures involving the metacarpals or phalanges can be sentinels of serious associated soft tissue injuries.²⁷

Phalangeal fractures can potentially affect the function of the entire hand; therefore, no malrotation is acceptable for phalangeal fractures because they can lead to overlap and malalignment of the digit. Displaced or malrotated fractures should be reduced either by closed or open techniques. Acceptable reduction is <6 mm of shortening, <15° of angulation, and no rotational deformity.^27,28 Nondisplaced phalangeal fractures can be treated nonoperatively with buddy taping and splinting with good results.²⁷ Interphalangeal (IP) dislocations can be reduced on the sidelines and then taped or splinted. Any injury with a force significant enough to cause joint dislocation indicates further evaluation for associated fractures and ligamentous injury or tear. The proximal interphalangeal (PIP) joint is the most common IP joint dislocation and is usually a dorsal dislocation. Reduction is often achieved by traction and flexion of the middle phalanx,²⁷ followed by splinting of the finger with the PIP in 30° of flexion or an extension block splint.²⁹ Successful reduction with no associated intra-articular fractures involving more than a third of the joint can be further managed nonoperatively with the splint, allowing 2 to 4 weeks for the volar plate, joint capsule, and collateral ligaments to heal. Additional 2 to 4 weeks of splinting with buddy taping to the adjacent finger is usually recommended.²⁹

The “Mallet finger” injury can be observed in goalkeepers and is caused by a flexion force on the tip of the finger while the distal interphalangeal (DIP) joint is extended. This force results in tearing of the extensor tendon or an avulsion fracture at the tendinous attachment on the dorsal lip of the distal phalangeal base. The classic mechanism of injury is an extended finger struck on the tip by a ball. Physical examination will indicate loss of DIP joint active extension, and the joint rests in an abnormally flexed position. Treatment typically consists of splinting the DIP joint in extension for 6 to 8 weeks. Operative treatment is reserved for severe injuries or fractures involving greater than one-third of the articular surface of the DIP joint or with failed nonoperative treatment.²⁷ 

Metacarpal fractures can be subdivided into distal, metacarpal neck, metacarpal shaft, and metacarpal base fractures. Metacarpal shaft fractures raise a specific concern regarding rotation, because even a small degree of rotation can create a substantial degree of deformity at the fingertip. This concern must be addressed during evaluation of the player. Fractures of the metacarpal base most commonly involve the fourth and fifth metacarpals and are often reduced easily but have a tendency to re-subluxate, which may indicate operative treatment. Most fractures of the metacarpals are low energy and result in simple fracture patterns that can be treated nonoperatively. Open reduction is reserved for high-energy trauma, fractures with excessive angulation, or multiple fractures.²⁷

Continue to: An important subgroup of metacarpal injuries...

An important subgroup of metacarpal injuries involves the base of the thumb. These injuries result from an axial load applied to the thumb. The most common injury is the “Bennett fracture,” which is an intra-articular fracture or dislocation involving the base of the first metacarpal. Bennett fractures are unstable fractures; unless properly recognized and treated, this intra-articular fracture subluxation may result in an unstable arthritic first carpometacarpal joint. These fractures are most commonly treated with closed or open reduction combined with internal fixation.²⁷ “Rolando fractures” are similar in location and etiology but are comminuted and usually require operative treatment.^{27, 29}

Another common hand injury found in soccer goalkeepers and involving the base of the thumb is disruption of the ulnar collateral ligament (UCL) of the first metacarpophalangeal (MCP) joint as a result of an acute radial or valgus stress on the thumb. Known as “gamekeeper’s thumb” or “skier’s thumb,” this injury can occur in the form of an avulsion fracture, an isolated ligament tear, or combined fracture and ligament rupture. On examination, swelling and tenderness over the thumb UCL are observed. A MCP joint stress test should be performed by gently applying a radially directed force to the thumb while stabilizing the metacarpal bone at both 0° and 30° at the MCP joint. Increased laxity, a soft or nonexistent end point, and gaping of the joint, as compared with the contralateral side, will indicate this injury.²⁹ Radiographs may show a small avulsion fracture fragment at the ulnar aspect of the base of the first metacarpal and at the attachment of the UCL. A Stener lesion is an abnormality that occurs when the thumb adductor muscle aponeurosis interposes between the 2 ends of the ruptured UCL, preventing UCL healing by immobilization alone. Ultrasound and MRI are additional imaging modalities that can assist with the diagnosis of a Stener lesion. The presence of a Stener lesion is a prime indication for surgical intervention. A nondisplaced fracture or isolated ligament injury with no evidence of a Stener lesion can be treated nonoperatively with splinting of the thumb and may lead to healing and restoration of stability. However, in professional players, surgical repair is often times preferred.²⁷

CONCLUSION

Upper extremity injuries are less common injuries among soccer players, but their prevalence is on the rise in recent years. Modern playing tactics and the increase in participation in soccer in younger age groups may be 2 contributing factors to this rise. Given the characteristics of their unique playing role and specific demands, the risk for upper extremity injuries among goalkeepers is significantly higher than that in outfielders and will usually result in a long absence period from soccer before they return to play. A thorough understanding of the mechanism of injury, players’ complaints and presentation, osseous and soft tissue involvement based on a systematic physical examination, imaging features, and treatment options is important for the optimal care of the players. Prompt and accurate diagnosis and appropriate management are essential for improved outcomes and timely return to play.

Unsurprisingly, upper extremity injuries are reported to be up to 5 times more common in goalkeepers than in outfield players,^1,2 reaching a high rate of up to 18% of all injuries among professional goalkeepers. The usage of upper extremities to stop the ball and repeated reaching to the ball and landing on the ground with changing upper extremity positions are some of the contributors to the increased upper extremity injury risk in goalkeepers.

Following 57 male professional European soccer teams from 16 countries between the years 2001 and 2011, Ekstrand and colleagues¹ showed that 90% of upper extremity injuries are traumatic, and only 10% are related to overuse. They also reported that the most common upper extremity injury location is the shoulder/clavicle (56%), followed by the hand/finger/thumb (24%), elbow (10%), wrist (5%), forearm (4%), and upper arm (1%). Specifically, the 6 most common injuries are acromioclavicular joint (ACJ) sprain (13%), shoulder dislocation (12%), hand metacarpal fracture (8%), shoulder rotator cuff tendinopathy (6%), hand phalanx fracture (6%), and shoulder ACJ dislocation (5%). 

This article will discuss common upper extremity injuries observed in soccer players, focusing on proper diagnosis and optimal management.

Continue to: THE SHOULDER...

THE SHOULDER

The majority of upper extremity injuries in professional soccer players are shoulder injuries.^1,2,4 Almost a third of these injuries (28%) are considered severe, preventing participation in training and matches for 28 days or more.⁶Ekstrand and colleagues¹ reported that shoulder dislocation represents the most severe upper extremity injury with a mean of 41 days of absence from soccer. When considering the position of the player, they further demonstrated that absence from full training and matches is twice as long for goalkeepers as for outfield players, which reflects the importance of shoulder function for goalkeepers.

In terms of the mechanism of shoulder instability injuries in soccer players, more than half (56%) of these injuries occur with a high-energy mechanism in the recognized position of combined humeral abduction and external rotation against a force of external rotation and horizontal extension.³ However, almost a quarter (24%) occur with a mechanism of varied upper extremity position and low-energy trauma, and 20% of injuries are either a low energy injury with little or no contact or gradual onset. These unique characteristics of shoulder instability injuries in soccer players should be accounted for during training and may imply that current training programs are suboptimal for the prevention of upper extremity injuries and shoulder injuries. Ejnisman and colleagues² reported on the development of a Fédération Internationale de Football Association (FIFA) 11+ shoulder injury prevention program for soccer goalkeepers as one of the ways to promote training programs that address the risk of shoulder injuries.

Reporting on the management of severe shoulder injuries requiring surgery in 25 professional soccer players in England, between 2007 and 2011, Hart and Funk³ found that the majority of subjects (88%) reported a dislocation as a feature of their presentation. Twenty-one (84%) subjects were diagnosed with labral injuries, of which 7 had an associated Hill-Sachs lesion. Two (8%) subjects were diagnosed with rotator cuff tears requiring repair, and 2 (8%) subjects had a combination of rotator cuff and labral injury repair. All patients underwent arthroscopic repair, except for 5 who had a Latarjet coracoid transfer. Post-surgery, all players were able to return to unrestricted participation in soccer at a mean of 11.4 weeks, with no significant difference between goalkeepers and outfield players and no recurrences at a mean of 91 weeks’ follow-up. 

Up to one-third of shoulder instability injuries in soccer players are reported to be recurrences,^1,3 which emphasizes the need to carefully assess soccer players before clearing them to return to play. These data raise the controversy over the treatment of first time shoulder dislocators and may support early surgical intervention.^7-9 In terms of the preferred surgical intervention in these cases, Balg and Boileau¹⁰ suggested a simple scoring system based on factors derived from a preoperative questionnaire, physical examination, and anteroposterior radiographs to help distinguish between patients who will benefit from an arthroscopic anterior stabilization using suture anchors and those who will require a bony procedure (open or arthroscopic). Cerciello and colleagues¹¹ reported excellent results for bony stabilization (modified Latarjet) in a population of 26 soccer players (28 shoulders) affected by chronic anterior instability. Only 1 player did not return to soccer, and 18 players (20 shoulders, 71%) returned to the same level. One re-dislocation was noted in a goalkeeper 74 months after surgery.

An injury to the ACJ has been previously reported to be the most prevalent type of shoulder injury in contact sports.¹²In soccer, injury to the ACJ is responsible for 18% of upper extremity injuries, and the majority (72%) are sprains.¹Interestingly, but unsurprisingly, implications of such an injury differ significantly between goalkeepers and outfield players with up to 3 times longer required absence periods for goalkeepers vs outfield players sustaining the same injury.

ACJ injury is commonly the result of a direct fall on the shoulder with the arm adducted or extended. Six grades of ACJ injuries have been described and distinguished by the injured anatomical structure (acromioclavicular ligaments and coracoclavicular ligaments) and the direction and magnitude of clavicular dislocation.^13,14 Presentation will usually include anterior shoulder pain, a noticeable swelling or change in morphology of the lateral end of the clavicle (mainly in dislocation types), and sharp pain provoked by palpation of the ACJ. Radiographic imaging will confirm the diagnosis and help with identifying the specific grade/type of injury.

Decision making and management of acute ACJ injury should be based on the type/grade of injury. Nonoperative treatment is recommended for types I and II, and most athletes have a successful outcome with a full return to play.¹²Types IV, V, and VI are treated early with operative intervention, mostly due to the morbidity associated with prolonged dislocation of the joint and subsequent soft tissue damage.¹² Treatment of type III injury remains controversial. Pereira-Graterol and colleagues¹⁵ reported the effectiveness of clavicular hook plate (DePuy Synthes) in the surgical stabilization of grade III ACJ dislocation in 11 professional soccer players. At a mean follow-up of 4 years, they showed excellent functional results with full shoulder range of motion at 5 weeks and latest return to soccer at 6 months. The hook plate was removed after 16 weeks in 10 patients in whom no apparent complication was observed.

Continue to: THE ELBOW...

THE ELBOW

Ekstrand and colleagues¹ reported that 10% of all upper extremity injuries in professional soccer players are elbow injuries, of which only 19% are considered severe injuries that require more than 28 days of absence from playing soccer. The most common elbow injuries in their cohort were elbow medial collateral ligament (MCL) sprain and olecranon bursitis.

Elbow MCL is the primary constraint of the elbow joint to valgus stress, and MCL sprain occurs when the elbow is subjected to a valgus, or laterally directed force, which distracts the medial side of the elbow, exceeding the tensile properties of the MCL.¹⁶ A thorough physical examination that includes valgus stress tests through the arc of elbow flexion and extension to elicit a possible subjective feeling of apprehension, instability, or localized pain is essential for optimal evaluation and treatment.^16,17 Imaging studies (X-ray and stress X-rays, dynamic ultrasound, computed tomography [CT], magnetic resonance imaging [MRI], and MR arthrography) have a role in further establishing the diagnosis and identifying possible additional associated injuries.¹⁶ The treatment plan should be specifically tailored to the individual athlete, depending on his demands and the degree of MCL injury. In soccer, which is a non-throwing shoulder sport, nonoperative treatment should be the preferred initial treatment in most cases. Ekstrand and colleagues¹ showed that this injury requires a mean of 4 days of absence from soccer for outfield players and a mean of 21 days of absence from soccer for goalkeepers, thereby indicating more severe sprains and cautious return to soccer in goalkeepers. Athletes who fail nonoperative treatment are candidates for MCL reconstruction.¹⁶

The olecranon bursa is a synovium-lined sac that facilitates gliding between the olecranon and overlying skin. Olecranon bursitis is characterized by accumulation of fluid in the bursa with or without inflammation. The fluid can be serous, sanguineous, or purulent depending on the etiology.¹⁸ In soccer, traumatic etiology is common, but infection secondary to cuts or scratches of the skin around the elbow or previous therapeutic injections around the elbow should always be ruled out. Local pain, swelling, warmth, and redness are usually the presenting symptoms. Aseptic olecranon bursitis may be managed non-surgically with ‘‘benign neglect’’ and avoidance of pressure to the area, non-steroidal anti-inflammatory drugs, needle aspiration, corticosteroid injection, compression dressings, and/or padded splinting; whereas acute septic bursitis requires needle aspiration for diagnosis, appropriate oral or intravenous antibiotics directed toward the offending organism, and, when clinically indicated, surgical evacuation/excision of the bursa.¹⁸ When treating this condition with cortisone injection, possible complications, such as skin atrophy, secondary infection, and chronic local pain, have been reported and should be considered.¹⁹

Severe elbow injuries in professional athletes in general,^20-22 and soccer players specifically, are elbow subluxations/dislocations and elbow fracture. The mechanism of injury is usually contact injury with an opponent player or a fall on the palm with the arm extended. Posterolateral is the most common type of elbow dislocation. Elbow dislocations are further classified into simple (no associated fractures) and complex (associated with fractures) categories.²² Simple dislocations are usually treated with early mobilization after closed reduction; it is associated with a low risk for re-dislocation and with generally good results. The complex type of elbow fracture dislocation is more difficult to treat, has higher complication and re-dislocation rates, and requires operative treatment in most cases compared with simple dislocation.²² The “terrible triad” of the elbow (posterior elbow dislocation, radial head fracture, and coronoid fracture) represents a specific complex elbow dislocation scenario that is difficult to manage because of conflicting aims of ensuring elbow stability while maintaining early range of motion.²²

Isolated fracture around the elbow should be treated based on known principles of fracture management: mechanism of injury, fracture patterns, fracture displacement, intra-articular involvement, soft tissue condition, and associated injuries.

Continue to: THE WRIST...

THE WRIST

Ekstrand and colleagues¹ reported that 5% of all upper extremity injuries in their cohort of professional soccer players are wrist injuries, of which, only 2% are considered severe injuries that require >28 days of absence from playing soccer. The more common wrist injuries in soccer, which is considered a high-impact sport, are fractures (distal radius, scaphoid, capitate), and less reported injuries are dislocations (lunate, perilunate) and ligamentous injuries or tears (scapholunate ligament).²³

Distal radius fractures in high-impact sports, like soccer, usually occur as a result of a fall on an out-stretched hand and will usually be more comminuted, displaced, and intra-articular compared with low-impact sports.²³ All these aforementioned characteristics usually indicate surgical management of open reduction and internal fixation, which will allow for rapid start of rehabilitation and return to play.

Scaphoid fracture is the most common carpal bone fracture and presents unique challenges in terms of diagnosis and optimal treatment²⁴ in professional athletes. A typical injury scenario would be a player falling on an outstretched hand and sustaining a scaphoid fracture during a match or training session. The player may acknowledge some wrist pain but will often continue to play with minimal or no limitation. As wrist pain and swelling become more evident after the match/training session, the player will seek medical evaluation.²⁴ A complete wrist and upper extremity examination should be performed in addition to a specific assessment, which includes palpation of the distal scaphoid pole at the distal wrist flexion crease, palpation of the scaphoid waist through the wrist snuff box, and palpation dorsally just distal to the Lister tubercle at the scapholunate joint. Any wrist injury that results in decreased range of motion, snuff box swelling, and scaphoid tenderness should be further evaluated with imaging. Plain radiographs with special scaphoid views are the initial preferred imaging studies, but occult fracture will require an additional study such as a bone scan, CT, or MRI. Several studies have validated the benefit of MRI and the fact that it may outweigh the costs associated with lost productivity from unnecessary cast immobilization, especially in elite athletes.^23-25Casting the patient with a nondisplaced scaphoid waist fracture has been the traditional treatment; however, stiffness, weakness, and deconditioning that can occur with long-term casting required for scaphoid fractures are significant impairments for the professional athlete and usually end the player’s season. Surgical treatment, which was traditionally indicated for displaced or proximal pole fractures, is currently also considered for non-displaced scaphoid waist fractures in professional athletes. This treatment allows for a rapid return to the rehabilitation of the extremity and possible early return to professional sport. In view of the known complications (eg, malunion, nonunion, and avascular necrosis), return to soccer can be considered when imaging confirms advanced healing, which some consider as at least 50% of bone fracture bridging on CT scan, no pain, excellent motion, and at least 80% of normal grip strength.²⁴ Outfield players can return to play with a protective cast or brace until full healing is observed on imaging.

Continue to: THE HAND/FINGERS/THUMB...

THE HAND/FINGERS/THUMB

Almost a quarter of upper extremity injuries in professional soccer players were reported to involve the hand, fingers, and thumb. A quarter of them were classified as severe injuries requiring >28 days of absence from playing soccer.¹Specifically, hand metacarpal and phalanx fractures are the most common reported injuries in sports in general,²⁶ and in soccer,¹ and account for 14% of all upper extremity injuries¹ in professional soccer players. Goalkeepers require a functional hand to play, whereas an outfielder can play with protection on the injured area; thus, the period of absence from soccer in these injuries is significantly different between goalkeepers and outfielders with more than 4 times longer absence from soccer for a goalkeeper compared with an outfielder. The fifth ray has been shown to be the most frequently fractured ray in the hand in soccer with 51.7% of all hand fractures reported.²⁶ The common mechanism is a full hit on the hand, and a direct hit from the ball is another possible mechanism in goalkeepers.

In general, the diagnosis of hand injuries requires evaluation of the mechanism of injury and injury symptoms, proper and comprehensive physical examination of the whole extremity, and prompt imaging. In most cases, plain radiographs in several projections will suffice for the diagnosis of obvious fractures, but CT scan is an additional modality that allows for improved appreciation of occult or complex and comminuted fracture patterns. MRI or ultrasound can be used additionally whenever associated soft tissue injury is suspected. Optimal management of the hand is based on the specific characteristics of the fractures, which include location, direction of the fracture line, presence of comminution, displacement, articular involvement, and associated soft tissue injury. Nondisplaced extra-articular fractures often can be treated with buddy taping or splinting, whereas intra-articular fractures often require surgical treatment. Displaced fractures of the hand have a tendency to angulate volarly because of attachments of the interosseous muscles. Marginal fractures or avulsion fractures involving the metacarpals or phalanges can be sentinels of serious associated soft tissue injuries.²⁷

Phalangeal fractures can potentially affect the function of the entire hand; therefore, no malrotation is acceptable for phalangeal fractures because they can lead to overlap and malalignment of the digit. Displaced or malrotated fractures should be reduced either by closed or open techniques. Acceptable reduction is <6 mm of shortening, <15° of angulation, and no rotational deformity.^27,28 Nondisplaced phalangeal fractures can be treated nonoperatively with buddy taping and splinting with good results.²⁷ Interphalangeal (IP) dislocations can be reduced on the sidelines and then taped or splinted. Any injury with a force significant enough to cause joint dislocation indicates further evaluation for associated fractures and ligamentous injury or tear. The proximal interphalangeal (PIP) joint is the most common IP joint dislocation and is usually a dorsal dislocation. Reduction is often achieved by traction and flexion of the middle phalanx,²⁷ followed by splinting of the finger with the PIP in 30° of flexion or an extension block splint.²⁹ Successful reduction with no associated intra-articular fractures involving more than a third of the joint can be further managed nonoperatively with the splint, allowing 2 to 4 weeks for the volar plate, joint capsule, and collateral ligaments to heal. Additional 2 to 4 weeks of splinting with buddy taping to the adjacent finger is usually recommended.²⁹

The “Mallet finger” injury can be observed in goalkeepers and is caused by a flexion force on the tip of the finger while the distal interphalangeal (DIP) joint is extended. This force results in tearing of the extensor tendon or an avulsion fracture at the tendinous attachment on the dorsal lip of the distal phalangeal base. The classic mechanism of injury is an extended finger struck on the tip by a ball. Physical examination will indicate loss of DIP joint active extension, and the joint rests in an abnormally flexed position. Treatment typically consists of splinting the DIP joint in extension for 6 to 8 weeks. Operative treatment is reserved for severe injuries or fractures involving greater than one-third of the articular surface of the DIP joint or with failed nonoperative treatment.²⁷ 

Metacarpal fractures can be subdivided into distal, metacarpal neck, metacarpal shaft, and metacarpal base fractures. Metacarpal shaft fractures raise a specific concern regarding rotation, because even a small degree of rotation can create a substantial degree of deformity at the fingertip. This concern must be addressed during evaluation of the player. Fractures of the metacarpal base most commonly involve the fourth and fifth metacarpals and are often reduced easily but have a tendency to re-subluxate, which may indicate operative treatment. Most fractures of the metacarpals are low energy and result in simple fracture patterns that can be treated nonoperatively. Open reduction is reserved for high-energy trauma, fractures with excessive angulation, or multiple fractures.²⁷

Continue to: An important subgroup of metacarpal injuries...

An important subgroup of metacarpal injuries involves the base of the thumb. These injuries result from an axial load applied to the thumb. The most common injury is the “Bennett fracture,” which is an intra-articular fracture or dislocation involving the base of the first metacarpal. Bennett fractures are unstable fractures; unless properly recognized and treated, this intra-articular fracture subluxation may result in an unstable arthritic first carpometacarpal joint. These fractures are most commonly treated with closed or open reduction combined with internal fixation.²⁷ “Rolando fractures” are similar in location and etiology but are comminuted and usually require operative treatment.^{27, 29}

Another common hand injury found in soccer goalkeepers and involving the base of the thumb is disruption of the ulnar collateral ligament (UCL) of the first metacarpophalangeal (MCP) joint as a result of an acute radial or valgus stress on the thumb. Known as “gamekeeper’s thumb” or “skier’s thumb,” this injury can occur in the form of an avulsion fracture, an isolated ligament tear, or combined fracture and ligament rupture. On examination, swelling and tenderness over the thumb UCL are observed. A MCP joint stress test should be performed by gently applying a radially directed force to the thumb while stabilizing the metacarpal bone at both 0° and 30° at the MCP joint. Increased laxity, a soft or nonexistent end point, and gaping of the joint, as compared with the contralateral side, will indicate this injury.²⁹ Radiographs may show a small avulsion fracture fragment at the ulnar aspect of the base of the first metacarpal and at the attachment of the UCL. A Stener lesion is an abnormality that occurs when the thumb adductor muscle aponeurosis interposes between the 2 ends of the ruptured UCL, preventing UCL healing by immobilization alone. Ultrasound and MRI are additional imaging modalities that can assist with the diagnosis of a Stener lesion. The presence of a Stener lesion is a prime indication for surgical intervention. A nondisplaced fracture or isolated ligament injury with no evidence of a Stener lesion can be treated nonoperatively with splinting of the thumb and may lead to healing and restoration of stability. However, in professional players, surgical repair is often times preferred.²⁷

CONCLUSION

Upper extremity injuries are less common injuries among soccer players, but their prevalence is on the rise in recent years. Modern playing tactics and the increase in participation in soccer in younger age groups may be 2 contributing factors to this rise. Given the characteristics of their unique playing role and specific demands, the risk for upper extremity injuries among goalkeepers is significantly higher than that in outfielders and will usually result in a long absence period from soccer before they return to play. A thorough understanding of the mechanism of injury, players’ complaints and presentation, osseous and soft tissue involvement based on a systematic physical examination, imaging features, and treatment options is important for the optimal care of the players. Prompt and accurate diagnosis and appropriate management are essential for improved outcomes and timely return to play.

Unsurprisingly, upper extremity injuries are reported to be up to 5 times more common in goalkeepers than in outfield players,^1,2 reaching a high rate of up to 18% of all injuries among professional goalkeepers. The usage of upper extremities to stop the ball and repeated reaching to the ball and landing on the ground with changing upper extremity positions are some of the contributors to the increased upper extremity injury risk in goalkeepers.

Following 57 male professional European soccer teams from 16 countries between the years 2001 and 2011, Ekstrand and colleagues¹ showed that 90% of upper extremity injuries are traumatic, and only 10% are related to overuse. They also reported that the most common upper extremity injury location is the shoulder/clavicle (56%), followed by the hand/finger/thumb (24%), elbow (10%), wrist (5%), forearm (4%), and upper arm (1%). Specifically, the 6 most common injuries are acromioclavicular joint (ACJ) sprain (13%), shoulder dislocation (12%), hand metacarpal fracture (8%), shoulder rotator cuff tendinopathy (6%), hand phalanx fracture (6%), and shoulder ACJ dislocation (5%). 

This article will discuss common upper extremity injuries observed in soccer players, focusing on proper diagnosis and optimal management.

Continue to: THE SHOULDER...

THE SHOULDER

The majority of upper extremity injuries in professional soccer players are shoulder injuries.^1,2,4 Almost a third of these injuries (28%) are considered severe, preventing participation in training and matches for 28 days or more.⁶Ekstrand and colleagues¹ reported that shoulder dislocation represents the most severe upper extremity injury with a mean of 41 days of absence from soccer. When considering the position of the player, they further demonstrated that absence from full training and matches is twice as long for goalkeepers as for outfield players, which reflects the importance of shoulder function for goalkeepers.

In terms of the mechanism of shoulder instability injuries in soccer players, more than half (56%) of these injuries occur with a high-energy mechanism in the recognized position of combined humeral abduction and external rotation against a force of external rotation and horizontal extension.³ However, almost a quarter (24%) occur with a mechanism of varied upper extremity position and low-energy trauma, and 20% of injuries are either a low energy injury with little or no contact or gradual onset. These unique characteristics of shoulder instability injuries in soccer players should be accounted for during training and may imply that current training programs are suboptimal for the prevention of upper extremity injuries and shoulder injuries. Ejnisman and colleagues² reported on the development of a Fédération Internationale de Football Association (FIFA) 11+ shoulder injury prevention program for soccer goalkeepers as one of the ways to promote training programs that address the risk of shoulder injuries.

Reporting on the management of severe shoulder injuries requiring surgery in 25 professional soccer players in England, between 2007 and 2011, Hart and Funk³ found that the majority of subjects (88%) reported a dislocation as a feature of their presentation. Twenty-one (84%) subjects were diagnosed with labral injuries, of which 7 had an associated Hill-Sachs lesion. Two (8%) subjects were diagnosed with rotator cuff tears requiring repair, and 2 (8%) subjects had a combination of rotator cuff and labral injury repair. All patients underwent arthroscopic repair, except for 5 who had a Latarjet coracoid transfer. Post-surgery, all players were able to return to unrestricted participation in soccer at a mean of 11.4 weeks, with no significant difference between goalkeepers and outfield players and no recurrences at a mean of 91 weeks’ follow-up. 

Up to one-third of shoulder instability injuries in soccer players are reported to be recurrences,^1,3 which emphasizes the need to carefully assess soccer players before clearing them to return to play. These data raise the controversy over the treatment of first time shoulder dislocators and may support early surgical intervention.^7-9 In terms of the preferred surgical intervention in these cases, Balg and Boileau¹⁰ suggested a simple scoring system based on factors derived from a preoperative questionnaire, physical examination, and anteroposterior radiographs to help distinguish between patients who will benefit from an arthroscopic anterior stabilization using suture anchors and those who will require a bony procedure (open or arthroscopic). Cerciello and colleagues¹¹ reported excellent results for bony stabilization (modified Latarjet) in a population of 26 soccer players (28 shoulders) affected by chronic anterior instability. Only 1 player did not return to soccer, and 18 players (20 shoulders, 71%) returned to the same level. One re-dislocation was noted in a goalkeeper 74 months after surgery.

An injury to the ACJ has been previously reported to be the most prevalent type of shoulder injury in contact sports.¹²In soccer, injury to the ACJ is responsible for 18% of upper extremity injuries, and the majority (72%) are sprains.¹Interestingly, but unsurprisingly, implications of such an injury differ significantly between goalkeepers and outfield players with up to 3 times longer required absence periods for goalkeepers vs outfield players sustaining the same injury.

ACJ injury is commonly the result of a direct fall on the shoulder with the arm adducted or extended. Six grades of ACJ injuries have been described and distinguished by the injured anatomical structure (acromioclavicular ligaments and coracoclavicular ligaments) and the direction and magnitude of clavicular dislocation.^13,14 Presentation will usually include anterior shoulder pain, a noticeable swelling or change in morphology of the lateral end of the clavicle (mainly in dislocation types), and sharp pain provoked by palpation of the ACJ. Radiographic imaging will confirm the diagnosis and help with identifying the specific grade/type of injury.

Decision making and management of acute ACJ injury should be based on the type/grade of injury. Nonoperative treatment is recommended for types I and II, and most athletes have a successful outcome with a full return to play.¹²Types IV, V, and VI are treated early with operative intervention, mostly due to the morbidity associated with prolonged dislocation of the joint and subsequent soft tissue damage.¹² Treatment of type III injury remains controversial. Pereira-Graterol and colleagues¹⁵ reported the effectiveness of clavicular hook plate (DePuy Synthes) in the surgical stabilization of grade III ACJ dislocation in 11 professional soccer players. At a mean follow-up of 4 years, they showed excellent functional results with full shoulder range of motion at 5 weeks and latest return to soccer at 6 months. The hook plate was removed after 16 weeks in 10 patients in whom no apparent complication was observed.

Continue to: THE ELBOW...

THE ELBOW

Ekstrand and colleagues¹ reported that 10% of all upper extremity injuries in professional soccer players are elbow injuries, of which only 19% are considered severe injuries that require more than 28 days of absence from playing soccer. The most common elbow injuries in their cohort were elbow medial collateral ligament (MCL) sprain and olecranon bursitis.

Elbow MCL is the primary constraint of the elbow joint to valgus stress, and MCL sprain occurs when the elbow is subjected to a valgus, or laterally directed force, which distracts the medial side of the elbow, exceeding the tensile properties of the MCL.¹⁶ A thorough physical examination that includes valgus stress tests through the arc of elbow flexion and extension to elicit a possible subjective feeling of apprehension, instability, or localized pain is essential for optimal evaluation and treatment.^16,17 Imaging studies (X-ray and stress X-rays, dynamic ultrasound, computed tomography [CT], magnetic resonance imaging [MRI], and MR arthrography) have a role in further establishing the diagnosis and identifying possible additional associated injuries.¹⁶ The treatment plan should be specifically tailored to the individual athlete, depending on his demands and the degree of MCL injury. In soccer, which is a non-throwing shoulder sport, nonoperative treatment should be the preferred initial treatment in most cases. Ekstrand and colleagues¹ showed that this injury requires a mean of 4 days of absence from soccer for outfield players and a mean of 21 days of absence from soccer for goalkeepers, thereby indicating more severe sprains and cautious return to soccer in goalkeepers. Athletes who fail nonoperative treatment are candidates for MCL reconstruction.¹⁶

The olecranon bursa is a synovium-lined sac that facilitates gliding between the olecranon and overlying skin. Olecranon bursitis is characterized by accumulation of fluid in the bursa with or without inflammation. The fluid can be serous, sanguineous, or purulent depending on the etiology.¹⁸ In soccer, traumatic etiology is common, but infection secondary to cuts or scratches of the skin around the elbow or previous therapeutic injections around the elbow should always be ruled out. Local pain, swelling, warmth, and redness are usually the presenting symptoms. Aseptic olecranon bursitis may be managed non-surgically with ‘‘benign neglect’’ and avoidance of pressure to the area, non-steroidal anti-inflammatory drugs, needle aspiration, corticosteroid injection, compression dressings, and/or padded splinting; whereas acute septic bursitis requires needle aspiration for diagnosis, appropriate oral or intravenous antibiotics directed toward the offending organism, and, when clinically indicated, surgical evacuation/excision of the bursa.¹⁸ When treating this condition with cortisone injection, possible complications, such as skin atrophy, secondary infection, and chronic local pain, have been reported and should be considered.¹⁹

Severe elbow injuries in professional athletes in general,^20-22 and soccer players specifically, are elbow subluxations/dislocations and elbow fracture. The mechanism of injury is usually contact injury with an opponent player or a fall on the palm with the arm extended. Posterolateral is the most common type of elbow dislocation. Elbow dislocations are further classified into simple (no associated fractures) and complex (associated with fractures) categories.²² Simple dislocations are usually treated with early mobilization after closed reduction; it is associated with a low risk for re-dislocation and with generally good results. The complex type of elbow fracture dislocation is more difficult to treat, has higher complication and re-dislocation rates, and requires operative treatment in most cases compared with simple dislocation.²² The “terrible triad” of the elbow (posterior elbow dislocation, radial head fracture, and coronoid fracture) represents a specific complex elbow dislocation scenario that is difficult to manage because of conflicting aims of ensuring elbow stability while maintaining early range of motion.²²

Isolated fracture around the elbow should be treated based on known principles of fracture management: mechanism of injury, fracture patterns, fracture displacement, intra-articular involvement, soft tissue condition, and associated injuries.

Continue to: THE WRIST...

THE WRIST

Ekstrand and colleagues¹ reported that 5% of all upper extremity injuries in their cohort of professional soccer players are wrist injuries, of which, only 2% are considered severe injuries that require >28 days of absence from playing soccer. The more common wrist injuries in soccer, which is considered a high-impact sport, are fractures (distal radius, scaphoid, capitate), and less reported injuries are dislocations (lunate, perilunate) and ligamentous injuries or tears (scapholunate ligament).²³

Distal radius fractures in high-impact sports, like soccer, usually occur as a result of a fall on an out-stretched hand and will usually be more comminuted, displaced, and intra-articular compared with low-impact sports.²³ All these aforementioned characteristics usually indicate surgical management of open reduction and internal fixation, which will allow for rapid start of rehabilitation and return to play.

Scaphoid fracture is the most common carpal bone fracture and presents unique challenges in terms of diagnosis and optimal treatment²⁴ in professional athletes. A typical injury scenario would be a player falling on an outstretched hand and sustaining a scaphoid fracture during a match or training session. The player may acknowledge some wrist pain but will often continue to play with minimal or no limitation. As wrist pain and swelling become more evident after the match/training session, the player will seek medical evaluation.²⁴ A complete wrist and upper extremity examination should be performed in addition to a specific assessment, which includes palpation of the distal scaphoid pole at the distal wrist flexion crease, palpation of the scaphoid waist through the wrist snuff box, and palpation dorsally just distal to the Lister tubercle at the scapholunate joint. Any wrist injury that results in decreased range of motion, snuff box swelling, and scaphoid tenderness should be further evaluated with imaging. Plain radiographs with special scaphoid views are the initial preferred imaging studies, but occult fracture will require an additional study such as a bone scan, CT, or MRI. Several studies have validated the benefit of MRI and the fact that it may outweigh the costs associated with lost productivity from unnecessary cast immobilization, especially in elite athletes.^23-25Casting the patient with a nondisplaced scaphoid waist fracture has been the traditional treatment; however, stiffness, weakness, and deconditioning that can occur with long-term casting required for scaphoid fractures are significant impairments for the professional athlete and usually end the player’s season. Surgical treatment, which was traditionally indicated for displaced or proximal pole fractures, is currently also considered for non-displaced scaphoid waist fractures in professional athletes. This treatment allows for a rapid return to the rehabilitation of the extremity and possible early return to professional sport. In view of the known complications (eg, malunion, nonunion, and avascular necrosis), return to soccer can be considered when imaging confirms advanced healing, which some consider as at least 50% of bone fracture bridging on CT scan, no pain, excellent motion, and at least 80% of normal grip strength.²⁴ Outfield players can return to play with a protective cast or brace until full healing is observed on imaging.

Continue to: THE HAND/FINGERS/THUMB...

THE HAND/FINGERS/THUMB

Almost a quarter of upper extremity injuries in professional soccer players were reported to involve the hand, fingers, and thumb. A quarter of them were classified as severe injuries requiring >28 days of absence from playing soccer.¹Specifically, hand metacarpal and phalanx fractures are the most common reported injuries in sports in general,²⁶ and in soccer,¹ and account for 14% of all upper extremity injuries¹ in professional soccer players. Goalkeepers require a functional hand to play, whereas an outfielder can play with protection on the injured area; thus, the period of absence from soccer in these injuries is significantly different between goalkeepers and outfielders with more than 4 times longer absence from soccer for a goalkeeper compared with an outfielder. The fifth ray has been shown to be the most frequently fractured ray in the hand in soccer with 51.7% of all hand fractures reported.²⁶ The common mechanism is a full hit on the hand, and a direct hit from the ball is another possible mechanism in goalkeepers.

In general, the diagnosis of hand injuries requires evaluation of the mechanism of injury and injury symptoms, proper and comprehensive physical examination of the whole extremity, and prompt imaging. In most cases, plain radiographs in several projections will suffice for the diagnosis of obvious fractures, but CT scan is an additional modality that allows for improved appreciation of occult or complex and comminuted fracture patterns. MRI or ultrasound can be used additionally whenever associated soft tissue injury is suspected. Optimal management of the hand is based on the specific characteristics of the fractures, which include location, direction of the fracture line, presence of comminution, displacement, articular involvement, and associated soft tissue injury. Nondisplaced extra-articular fractures often can be treated with buddy taping or splinting, whereas intra-articular fractures often require surgical treatment. Displaced fractures of the hand have a tendency to angulate volarly because of attachments of the interosseous muscles. Marginal fractures or avulsion fractures involving the metacarpals or phalanges can be sentinels of serious associated soft tissue injuries.²⁷

Phalangeal fractures can potentially affect the function of the entire hand; therefore, no malrotation is acceptable for phalangeal fractures because they can lead to overlap and malalignment of the digit. Displaced or malrotated fractures should be reduced either by closed or open techniques. Acceptable reduction is <6 mm of shortening, <15° of angulation, and no rotational deformity.^27,28 Nondisplaced phalangeal fractures can be treated nonoperatively with buddy taping and splinting with good results.²⁷ Interphalangeal (IP) dislocations can be reduced on the sidelines and then taped or splinted. Any injury with a force significant enough to cause joint dislocation indicates further evaluation for associated fractures and ligamentous injury or tear. The proximal interphalangeal (PIP) joint is the most common IP joint dislocation and is usually a dorsal dislocation. Reduction is often achieved by traction and flexion of the middle phalanx,²⁷ followed by splinting of the finger with the PIP in 30° of flexion or an extension block splint.²⁹ Successful reduction with no associated intra-articular fractures involving more than a third of the joint can be further managed nonoperatively with the splint, allowing 2 to 4 weeks for the volar plate, joint capsule, and collateral ligaments to heal. Additional 2 to 4 weeks of splinting with buddy taping to the adjacent finger is usually recommended.²⁹

The “Mallet finger” injury can be observed in goalkeepers and is caused by a flexion force on the tip of the finger while the distal interphalangeal (DIP) joint is extended. This force results in tearing of the extensor tendon or an avulsion fracture at the tendinous attachment on the dorsal lip of the distal phalangeal base. The classic mechanism of injury is an extended finger struck on the tip by a ball. Physical examination will indicate loss of DIP joint active extension, and the joint rests in an abnormally flexed position. Treatment typically consists of splinting the DIP joint in extension for 6 to 8 weeks. Operative treatment is reserved for severe injuries or fractures involving greater than one-third of the articular surface of the DIP joint or with failed nonoperative treatment.²⁷ 

Metacarpal fractures can be subdivided into distal, metacarpal neck, metacarpal shaft, and metacarpal base fractures. Metacarpal shaft fractures raise a specific concern regarding rotation, because even a small degree of rotation can create a substantial degree of deformity at the fingertip. This concern must be addressed during evaluation of the player. Fractures of the metacarpal base most commonly involve the fourth and fifth metacarpals and are often reduced easily but have a tendency to re-subluxate, which may indicate operative treatment. Most fractures of the metacarpals are low energy and result in simple fracture patterns that can be treated nonoperatively. Open reduction is reserved for high-energy trauma, fractures with excessive angulation, or multiple fractures.²⁷

Continue to: An important subgroup of metacarpal injuries...

An important subgroup of metacarpal injuries involves the base of the thumb. These injuries result from an axial load applied to the thumb. The most common injury is the “Bennett fracture,” which is an intra-articular fracture or dislocation involving the base of the first metacarpal. Bennett fractures are unstable fractures; unless properly recognized and treated, this intra-articular fracture subluxation may result in an unstable arthritic first carpometacarpal joint. These fractures are most commonly treated with closed or open reduction combined with internal fixation.²⁷ “Rolando fractures” are similar in location and etiology but are comminuted and usually require operative treatment.^{27, 29}

Another common hand injury found in soccer goalkeepers and involving the base of the thumb is disruption of the ulnar collateral ligament (UCL) of the first metacarpophalangeal (MCP) joint as a result of an acute radial or valgus stress on the thumb. Known as “gamekeeper’s thumb” or “skier’s thumb,” this injury can occur in the form of an avulsion fracture, an isolated ligament tear, or combined fracture and ligament rupture. On examination, swelling and tenderness over the thumb UCL are observed. A MCP joint stress test should be performed by gently applying a radially directed force to the thumb while stabilizing the metacarpal bone at both 0° and 30° at the MCP joint. Increased laxity, a soft or nonexistent end point, and gaping of the joint, as compared with the contralateral side, will indicate this injury.²⁹ Radiographs may show a small avulsion fracture fragment at the ulnar aspect of the base of the first metacarpal and at the attachment of the UCL. A Stener lesion is an abnormality that occurs when the thumb adductor muscle aponeurosis interposes between the 2 ends of the ruptured UCL, preventing UCL healing by immobilization alone. Ultrasound and MRI are additional imaging modalities that can assist with the diagnosis of a Stener lesion. The presence of a Stener lesion is a prime indication for surgical intervention. A nondisplaced fracture or isolated ligament injury with no evidence of a Stener lesion can be treated nonoperatively with splinting of the thumb and may lead to healing and restoration of stability. However, in professional players, surgical repair is often times preferred.²⁷

CONCLUSION

Upper extremity injuries are less common injuries among soccer players, but their prevalence is on the rise in recent years. Modern playing tactics and the increase in participation in soccer in younger age groups may be 2 contributing factors to this rise. Given the characteristics of their unique playing role and specific demands, the risk for upper extremity injuries among goalkeepers is significantly higher than that in outfielders and will usually result in a long absence period from soccer before they return to play. A thorough understanding of the mechanism of injury, players’ complaints and presentation, osseous and soft tissue involvement based on a systematic physical examination, imaging features, and treatment options is important for the optimal care of the players. Prompt and accurate diagnosis and appropriate management are essential for improved outcomes and timely return to play.

With an estimated 1.6 to 3.8 million sports-related mild traumatic brain injuries (ie, concussions) occurring annually in the United States,¹ there has been an appropriate increase in the focus on prevention and treatment of these injuries. For more than a decade the spotlight has been on concussions that occur in American football, but other sports have also had to examine the prevalence of concussions in their sport. This is certainly true for soccer.

There has been a steady increase in soccer participation in the United States. From 1973 to 2014 there was a 4-fold increase in high school boys and a 35-fold increase in high school girls playing soccer.² Currently, there are more than 3.7 million youth who play on teams under the supervision of the US Soccer Federation, the sport’s national governing body.³ With the growth of the sport, there has also been an intensified focus on injury prevention in soccer players, including concussive brain injuries.

A recent study examined injury rates in high school soccer players and noted that concussion is the second most common injury (17.9%), after ligament sprains (29.7%).⁴ The overall injury rate was 2.06 per 1000 athletic exposures (AEs [defined as participation in practice or game play]), but higher in games (4.42 per 1000 AEs) than during practices (1.05 per 1000 AEs). The overall concussion rate was 0.36 per 1000 AEs.⁴

Most concussions (54.8%) resulted in missing play between 1 to 3 weeks, but a sizeable portion of the athletes (14.9%) were out of play for more than 3 weeks. Additionally, 10.7% of all medical disqualifications were due to concussive injuries. Khodaee and colleagues⁴ found no statistically significant difference in concussion rates between male and female soccer players over the 9-year period of time that they examined, however previous studies have found higher rates in female athletes.⁵

In soccer, as in other sports, there is a concern about both the adequate recognition of concussions during practice and play and the underreporting of concussions by athletes. The US Soccer Federation has taken a proactive stance on addressing concussion in youth soccer by developing the “Recognize to Recover” program.⁶ Recognize to Recover is the US Soccer Federation’s “comprehensive player health and safety program aimed at promoting safe play and reducing injuries in soccer players of all ages.” The website provides an educational video geared toward players, along with links to concussion assessment tools, the US Soccer Federation Concussion Protocol, and US Soccer Federation-Centers for Disease Control fact sheets for athletes, parents, and coaches.⁶

Continue to: A challenge for all sports...

A challenge for all sports is allowing adequate evaluation of a suspected concussion by properly trained healthcare professionals. The 2017 Berlin Concussion in Sport Group position paper stated, “when a concussion is suspected, the athlete should be removed from the sporting environment and a multimodal assessment should be conducted in standardized fashion (eg, Sport Concussion Assessment Tool- 5th edition). Sporting bodies should allow adequate time to conduct this evaluation.”⁷ However, the International Federation of Football Association (FIFA) rules limit substitutions to 3 over the course of the game, which can make a thorough evaluation of players difficult as trainers and coaches are under increased pressure to quickly determine whether to use one of their valuable substitutions. Fortunately, the National Collegiate Athletic Association (NCAA) soccer has mitigated this issue by allowing unlimited substitutions during matches, and high school teams generally follow similar rules.

One of the goals of any safety education program is not only to raise the awareness of the signs and symptoms of concussion by all those involved in the sport, but also to increase the number of athletes who self-report their symptoms and decrease those who hide any possible concussions. A study found that a majority (58.6%) of middle school soccer players continued to play while experiencing concussion symptoms.⁵ However, in a very recent (not yet published) study, 92% of US Soccer Federation players reported that they did seek out a medical evaluation for their concussion.⁸ This is certainly a positive sign and further research needs to clarify what methods of education or training will maintain this level of self-reporting in soccer players.

There has also been an increased focus on understanding the mechanism of injury of concussions. In soccer, concussions can occur from player-to-player contact, contact with the player surface, contact with playing apparatus (eg, goal posts) and non-contact mechanisms. While there has been a focus on concussions from heading the ball, player-to-player contact is the most common cause of concussions. A 2017 study of 7- to 12-year-old soccer players in 4 European countries found that about 1 out of 10 concussions were caused by heading the ball.⁹ Comstock and colleageues¹⁰ found slightly higher numbers, roughly 25% to 30% (depending on gender), but 70% to 78% (again depending on gender) of those were caused by player-to-player contact rather than contact with the ball.

To date there has not been any meta-analytic review evaluating the cognitive and physical symptoms associated with heading in soccer. A recent review paper stated that the “current evidence seems insufficient to support a ban of heading in children’s football (soccer).”¹⁰ However, in December 2015 the US Soccer Federation included age-specific heading limitations. Players ages 10 years and under “shall not engage in heading, either in practices or in games” and players age 11 years and 12 years should have “limited heading in practice; maximum of 30 minutes of heading training per week, with no more than 15-20 headers per player, per week.”¹¹ US Soccer Federation officials acknowledged the limitations in the current science regarding heading in young soccer players but chose to err on the side of caution until further empirical evidence regarding the risks associated with repetitive heading is available.

The US Soccer Federation is also exploring other ways to reduce the incidence rate of concussions, including ensuring that the age-appropriate sized ball is used in practice and play, possible rule changes, evaluation of different playing surfaces, and equipment usage. To date, there is no strong evidence to support the use of mouth guards or helmets to reduce concussions in soccer. Additionally, the current data about the value of head impact sensors in soccer has not supported its widespread use.

Continue to: Finally, the issue of the prevalence...

Finally, the issue of the prevalence of chronic traumatic encephalopathy (CTE) in soccer players is beyond the scope of this article. The expert opinion from the 2017 US Soccer Federation, Major League Soccer (MLS), and National Women’s Soccer League (NWSL) conference concluded, “At present, no data exist that support that soccer participation is a risk factor for the development of neurodegenerative disease. Similarly, at this time, consistent with evidence discussed in the Berlin Concussion in Sport Group (CISG) Consensus Conference, our review suggests no causal relationship has been demonstrated between soccer and CTE pathology.”¹²

The more we know about concussions, both in general and those sustained during soccer play, the better we are able to diagnose and manage these injuries in our athletes. An important step is creating evidence-based protocols that evolve as our knowledge of concussions does as well. In April 2017, the US Soccer Federation, MLS, and the NWSL held a joint summit entitled, “Head Injury in Soccer: From Science to the Field” to address the current evidence-based science of concussions in soccer.⁸ An article discussing the findings of this meeting is forthcoming and will undoubtedly guide further development of concussion protocols for soccer players of all ages.

HEART

The physiologic demands of soccer place considerable stress on the cardiovascular system. Participation in training and competition is characterized by a combination of aerobic and anaerobic physiology with the typical athlete covering approximately 10 km over the course of the 90-minute match. The primary role of the heart and blood vessels is to supply the exercising skeletal muscle with oxygen and energy substrate and to clear the byproducts of metabolism. Among healthy athletes without cardiovascular disease, these processes are typically well tolerated and may be associated with beneficial cardiovascular adaptations over time. However, competitive soccer players are not completely immune to cardiovascular disease. Athletes across the age and competition spectrum may develop symptoms suggestive of underlying cardiovascular disease during play including exertional chest pain, inappropriate shortness of breath, palpitations, and syncope. These athletes require timely clinical evaluation. In extremely rare but high visibility cases, competitive soccer players may succumb to cardiac arrest on the pitch, underscoring the need for comprehensive emergency action plans (EAPs). We provide the practicing clinician with an overview of cardiovascular issues relevant to the competitive soccer athlete.

CARDIOVASCULAR ADAPTATIONS TO SPORT

The pressure (ie, repetitive surges in systemic blood pressure) and volume (ie, sustained increases in high cardiac output) challenges inherent in soccer participation place stress on the cardiovascular system. Healthy athletes across the age spectrum typically tolerate the hemodynamic stressors of participation without issues. Athletes that engage in training and competition over months to years often develop beneficial adaptations of the cardiovascular system that enhance on-field performance and contribute to optimal long-term health. Detailed discussion of how the heart and blood vessels respond to exercise training is beyond the scope of this article, but the interested reader is referred to several prior publications.^13,14 In brief, the heart of the healthy soccer athlete demonstrates the balanced mild chamber dilation and wall thickening characteristic of left ventricular eccentric remodeling. This form of exercise-induced cardiac remodeling facilitates maintenance of high stroke volume during exercise with minimal increases in cardiac work. In parallel, routine aerobic exercise training confers favorable changes in the systemic arterial system, which leads to reductions in age-associated ventricular stiffening and maintenance of healthy low blood pressure. It must be emphasized that the healthy heart muscle dilation and thickening that develop in response to sports participation, regardless of age, ethnicity, or gender, are relatively mild and should not be confused with common forms of heart muscle disease that may be seen in athletes at risk for adverse outcomes. In some situations, consultation with an extreme sports cardiologist may be required to differentiate exercise-induced remodeling from over heart muscle pathology.¹⁵

Continue to: THE SYMPTOMATIC ATHLETE...

THE SYMPTOMATIC ATHLETE

Any athlete presenting with symptoms suggestive of underlying cardiovascular disease should be withheld from training and competition until a comprehensive clinical evaluation has been completed. Common manifestations of underlying heart disease that occur in soccer players include exertional chest pain/pressure/tightness, shortness of breath that is out of proportion to workload, palpitations or the perception of irregular cardiac activity, and syncope. Chest discomfort, inappropriate shortness of breath, and palpitations that occur during training or competition should be managed with immediate removal from the playing field and prompt medical assessment. In many cases, thorough evaluation will involve collaboration between sports medicine and sports cardiology providers. Evaluations must be individualized on a case-by-case basis as tailored to the athlete’s presenting chief complaint and prior medical history. Most of these assessments will include a detailed medical history and physical examination, a 12-lead electrocardiogram (ECG), provocative exercise testing in a controlled environment, noninvasive cardiac imaging, and in some cases ambulatory rhythm monitoring. Uniformly, the athlete should be withheld from further training and competition until high-risk cardiovascular disease has been excluded. We refer the interested reader to a comprehensive discussion of symptom-based assessment of the athlete with suspected cardiovascular disease.¹⁶

Syncope (sudden and abrupt loss of consciousness with spontaneous neurologic recovery) is common among trained athletes. The vast majority of syncope is caused by “neurocardiogenic” mechanisms and carries a benign prognosis. Benign neurally-mediated syncope most often occurs outside of training and competition among athletes with heightened vagal tone and a predisposed susceptibility to triggers including pain, anxiety, emotional stimulation, and sudden postural change. Athletes who experience neurally-mediated syncope outside of training and competition routinely report a pre-event prodrome or aura that permits them to lower themselves to the ground, thereby avoiding injury. A distinct, but similarly benign and common, form of neurally-mediated fainting is post-exertional syncope. Here, fainting occurs within seconds of abrupt termination of exercise due to a rapid reduction cardiac preload and corollary cerebral blood supply. When either form of neurally-mediated syncope is suggested by a comprehensive medical history, normal physical examination, and a normal 12- lead ECG, further evaluation is unnecessary. However, the athlete and their coaching staff should be educated about avoidance tactics including hydration, dietary sodium supplementation, and avoidance of abrupt exercise termination as neutrally-mediated syncope tends to be recurrent without such measures. Fainting episodes that occur during training or competition that are not clearly post-exertional should be considered a medical emergency and should prompt comprehensive evaluation by a qualified cardiovascular specialist. Working closely with team physicians and athletic training staff, it is the responsibility of sports cardiologists to exclude potentially life-threatening forms of electrical, muscular, coronary, and valvular heart disease. Ideally, this evaluation should be conducted rapidly to avoid unnecessary delays in return to play.

CARDIAC ARREST AND SUDDEN DEATH

Numerous high-visibility cases of cardiac arrest on the soccer pitch have alerted the sporting community to the potential for these rare and potentially tragic events. Definitive incidence statistics defining the risk of cardiac arrest among soccer players are lacking. Data from the NCAA database suggest a sudden death incidence rate among collegiate male soccer athletes of approximately 1:24,000 athlete years.⁸ Similar data documenting incidence among female athletes and among those at lower (ie, youth level and high school) and higher (ie, professional) levels of play are unavailable. Underlying cardiovascular disease in the forms of heart muscle abnormalities (ie, genetic and acquired cardiomyopathy), coronary artery abnormalities (ie, genetic coronary anomalies and atherosclerotic coronary disease), valvular heart problems (ie, congenitally malformed aortic valves), and primary disturbances of the cardiac electrical system (ie, Wolf-Parkinson-White syndrome, long QT syndrome, etc.) explain a substantial percentage of on-pitch cardiac arrest. However, it is increasingly recognized that a significant minority of sudden cardiac deaths among athletes occur in the absence of attributable cardiovascular abnormality.¹⁷ Such cases, often referred to as “sudden unexplained death,” present unique challenges in the context of pre-participation screening, as they are undetectable and thus unpredictable.

Reduction of cardiac arrest and sudden death may best be accomplished through a combination of focused pre-participation screening and the development and implementation of a comprehensive EAP. Pre-participation involves the performance of a battery of tests prior to training and competition that are geared toward the detection of occult high-risk cardiovascular disease. Recommendations regarding pre-participation screening vary both across and within countries. Current US recommendations call for a focused medical history and physical examination prior to training and competition with consideration of the addition of a 12-lead ECG on a local level based on expertise and available resources.¹⁸ Conversely, current European guidelines including those endorsed by FIFA, suggest routine inclusion of a 12-lead ECG and in some cases, a transthoracic ECG.¹⁹ It must be emphasized that no screening approach has been confirmed to reduce the incidence of sudden death, and the decision to extend screening beyond the medical history and physical examination to include a 12-lead ECG or echocardiogram may come at the cost of increased false positive testing. In practice, decisions about how and when to screen are ideally made at a local level after consideration of medical and financial resources.²⁰

Continue to: Even the most comprehensive approach...

Even the most comprehensive approach to screening and evaluation of symptomatic athletes will not completely eliminate on-pitch cardiac arrest. Thus, all stakeholders that engage in the oversight of organized soccer must be committed to the development and implementation of an EAP.²¹ Key components of an effective EAP include the training of coaching staff, athletic trainers, and players in basic cardiopulmonary resuscitation, access to and training in the use of automated external defibrillators, and a triage/transport protocol that ensures timely access to advanced cardiac life support. Much like screening, emergency action planning involving these key core components must be developed and tailored locally. In the era of contemporary organized athletics, the absence of an EAP at any level of competition, from youth to professional leagues, is unacceptable. Effective EAPs must be developed, documented, and rehearsed at regular intervals. For the health and safety of competitive soccer players, as well as coaching staff and spectators, these steps are of critical importance.

HEAT

Heat-related illnesses can be serious and, at times, even life threatening. It is important for athletic staff and athletes to be well versed in the prevention, signs and symptoms, and treatment of heat-related illnesses in order to prevent serious and lasting injury. We aim to educate physicians about the prevention, recognition, and management of heat-related injury, and stress the importance of similarly educating athletes and coaching staff.

Exertional heat illnesses most often occur at temperatures >86°F, however they can occur at any temperature with heavy exertion.²² Signs and symptoms can be nonspecific early on, including weakness, fatigue, headache, nausea, and dizziness. Later signs can include imbalance, altered mentation, confusion, and behavior that is out of character such as irritability or aggression.²³ It is easy to see how the later signs can be confused for concussion in the right context. We cover the recognition and treatment of two common and serious heat-related illnesses: heat exhaustion and exertional heat stroke (EHS).

HEAT EXHAUSTION

Heat exhaustion occurs when an athlete cannot continue to exercise due to weakness and fatigue. While the exact mechanism is not well understood, it has been established that the combined effect of heat and dehydration have been proven to decrease exercise capacity and performance to a greater degree than either alone. The heat created by the body during exercise is 15 to 20 times greater than when at rest, and can increase core body temperature by 1°C every 5 minutes if no heat is lost, such as through sweating.²⁴ Additionally, when fluid deficits reach >3% to 5% of total body water, sweat production and skin blood flow decline, blunting the ability for the body to cool itself and causing progressive elevation of core body temperature if the athlete continues exerting him or herself. When fluid deficits reach 6% to 10%, cardiac output, sweat, and muscle blood flow decrease, likely leading to the symptoms seen with heat exhaustion: weakness, profound fatigue, and occasionally confusion and disorientation. Athletes with suspected heat exhaustion should be moved to a cooler area, laid down with legs elevated, and orally rehydrated. If they do not improve with oral rehydration, they may require intravenous fluids. The diagnosis of heat exhaustion hinges on a rectal temperature of <104°F; if >104°F the athlete should be presumed to have heat stroke, which will be addressed in the following paragraphs. Players can be cleared to return to play in mild cases within 24 to 48 hours with gradual increases in exercise intensity.²⁴

EXERTIONAL HEAT STROKE

EHS occurs when the body can no longer regulate the core body temperature and it rises to upwards of 104°F. In EHS, elevated core body temperature is associated with evidence of end organ dysfunction. The most easily identified on the playing field is likely central nervous system dysfunction, including irritability, confusion, irrational behavior, lethargy, dizziness, confusion, and even loss of consciousness. Temperature should be measured with rectal temperature only, as other methods of measurement have been shown to be consistently inaccurate.²² Heat stroke can be confused with exertional hyponatremia, heat exhaustion, or concussion, especially when core body temperature cannot be determined. However, EHS should always be the presumed cause of altered mentation when no rectal temperature is available because rapid cooling is critical to minimizing lasting effects. Morbidity and mortality are directly related to the length of time required to cool the athlete under 40°C (104°F).²⁴ Cooling should be completed on site prior to transport to a medical facility and is best achieved with submersion in an ice bath (ie, a kiddie pool or soaking tub full of ice and water).^22,25 If an ice bath is not available, ice bags should be applied to the neck axilla and groin and exchanged for fresh bags every 2 to 3 minutes.²² Ice bags have been shown to be inferior to whole body cooling, only cooling the athlete .04°C to .08°C/min compared to .15°C to .24°C/min with the ice bath.²⁴ All other tests should be delayed until cooling is achieved, unless they can be completed while cooling the athlete. The athlete can be removed from the ice bath once rectal temperatures reach <101°F to 102°F.²³ If the athlete returns to baseline after cooling, transportation to a medical facility may not be necessary. However, they should refrain from physical activity and heat exposure for at least 7 days and should be evaluated by a physician at that time. If all labs are normal and the athlete is asymptomatic, they can start progressive return to play under the direction of an athletic trainer or a sports medicine physician.²³

Continue to: HEAT-RELATED ILLNESS...

HEAT-RELATED ILLNESS

It is impossible to predict exactly which athletes will be most at risk for heat-related illness, so it is important to have a high degree of suspicion when environmental conditions are right. Athletes with recent illness, fever, or lack of sleep are at higher risk. Additional intrinsic risk factors include low fitness level, obesity, and inadequate hydration. Athletes who are highly competitive or motivated can be more likely to push through the early signs of illness or be reluctant to report symptoms.²³ Those with a history of exertional heat illness are more at risk for developing it again in the future.²³

The extrinsic risk factors for the development of heat-related illness are much easier to identify and modify in order to keep athletes safe. High temperature and high humidity conditions, heavy sun exposure, and exposure to similar conditions the preceding day put athletes at risk for exertional heat illness. Risks are even greater when the exercise is prolonged or intense with few breaks and access to hydration is limited.²³ Therefore, prevention of exertional heat illness is centered on these external risk factors.

Each team should have a heat policy as part of their EAP aimed at prevention and early recognition of heat-related illness. This policy should be shared with all athletes and coaches. The plan should be centered on acclimatization, activity modification, and early recognition and management as previously discussed. The US Soccer Federation “Recognize to Recover” Heat Guidelines suggest a 3-step process for appropriate activity modification:²²

1. Find the wet bulb globe temperature, either using a wet bulb globe thermometer or the temperature and humidity (Figure 1).

2. Find your regional weather category on the map (Figure 2).

3. Find your alert level and work to rest ratio recommendations (Figure 3).

Scheduled hydration breaks should be given as listed in Figure 3. Breaks of 4 minutes should be given for each 30 minutes of continuous practice or play. In a regulation 90-minute match, a hydration break should be given at 30 and 75 minutes (with half time at 45 minutes) at minimum. Athletes should be educated about where hydration can be accessed, and given unlimited access to hydration even outside of planned breaks.²²

Acclimatization to conditions is another integral part of preventing heat-related illness. It allows the body time to adapt to exercising in heat gradually, with a measured progression of exertion over the course of 10 to 14 days. The “Recognize to Recover” Heat Guidelines also provide guidance on acclimatization, and specifics can be found on the website.¹ Generally speaking, the warmest part of the day, usually between 11 AM and 4 PM, should be avoided for all training sessions, and length of practice and exertion should be gradually increased over 2 weeks.²²

In summary, appropriate acclimatization, hydration, activity modification, and education of athletes and staff are essential for the prevention of heat-related illness. Athletes and staff should understand the signs and symptoms of heat-related illness so that it can be recognized early and treated appropriately. If an athlete is altered in the heat and rectal temperature is >104°F or rectal temperature cannot be obtained, rapid cooling using an ice bath or ice bags is essential to prevent the morbidity and mortality associated with EHS. Above all, teams should have an explicit plan that includes protocols for acclimatization, activity modification, and all necessary equipment to prevent and treat heat-related illnesses should they occur, and ultimately keep athletes safe and healthy.

With an estimated 1.6 to 3.8 million sports-related mild traumatic brain injuries (ie, concussions) occurring annually in the United States,¹ there has been an appropriate increase in the focus on prevention and treatment of these injuries. For more than a decade the spotlight has been on concussions that occur in American football, but other sports have also had to examine the prevalence of concussions in their sport. This is certainly true for soccer.

There has been a steady increase in soccer participation in the United States. From 1973 to 2014 there was a 4-fold increase in high school boys and a 35-fold increase in high school girls playing soccer.² Currently, there are more than 3.7 million youth who play on teams under the supervision of the US Soccer Federation, the sport’s national governing body.³ With the growth of the sport, there has also been an intensified focus on injury prevention in soccer players, including concussive brain injuries.

A recent study examined injury rates in high school soccer players and noted that concussion is the second most common injury (17.9%), after ligament sprains (29.7%).⁴ The overall injury rate was 2.06 per 1000 athletic exposures (AEs [defined as participation in practice or game play]), but higher in games (4.42 per 1000 AEs) than during practices (1.05 per 1000 AEs). The overall concussion rate was 0.36 per 1000 AEs.⁴

Most concussions (54.8%) resulted in missing play between 1 to 3 weeks, but a sizeable portion of the athletes (14.9%) were out of play for more than 3 weeks. Additionally, 10.7% of all medical disqualifications were due to concussive injuries. Khodaee and colleagues⁴ found no statistically significant difference in concussion rates between male and female soccer players over the 9-year period of time that they examined, however previous studies have found higher rates in female athletes.⁵

In soccer, as in other sports, there is a concern about both the adequate recognition of concussions during practice and play and the underreporting of concussions by athletes. The US Soccer Federation has taken a proactive stance on addressing concussion in youth soccer by developing the “Recognize to Recover” program.⁶ Recognize to Recover is the US Soccer Federation’s “comprehensive player health and safety program aimed at promoting safe play and reducing injuries in soccer players of all ages.” The website provides an educational video geared toward players, along with links to concussion assessment tools, the US Soccer Federation Concussion Protocol, and US Soccer Federation-Centers for Disease Control fact sheets for athletes, parents, and coaches.⁶

Continue to: A challenge for all sports...

A challenge for all sports is allowing adequate evaluation of a suspected concussion by properly trained healthcare professionals. The 2017 Berlin Concussion in Sport Group position paper stated, “when a concussion is suspected, the athlete should be removed from the sporting environment and a multimodal assessment should be conducted in standardized fashion (eg, Sport Concussion Assessment Tool- 5th edition). Sporting bodies should allow adequate time to conduct this evaluation.”⁷ However, the International Federation of Football Association (FIFA) rules limit substitutions to 3 over the course of the game, which can make a thorough evaluation of players difficult as trainers and coaches are under increased pressure to quickly determine whether to use one of their valuable substitutions. Fortunately, the National Collegiate Athletic Association (NCAA) soccer has mitigated this issue by allowing unlimited substitutions during matches, and high school teams generally follow similar rules.

One of the goals of any safety education program is not only to raise the awareness of the signs and symptoms of concussion by all those involved in the sport, but also to increase the number of athletes who self-report their symptoms and decrease those who hide any possible concussions. A study found that a majority (58.6%) of middle school soccer players continued to play while experiencing concussion symptoms.⁵ However, in a very recent (not yet published) study, 92% of US Soccer Federation players reported that they did seek out a medical evaluation for their concussion.⁸ This is certainly a positive sign and further research needs to clarify what methods of education or training will maintain this level of self-reporting in soccer players.

There has also been an increased focus on understanding the mechanism of injury of concussions. In soccer, concussions can occur from player-to-player contact, contact with the player surface, contact with playing apparatus (eg, goal posts) and non-contact mechanisms. While there has been a focus on concussions from heading the ball, player-to-player contact is the most common cause of concussions. A 2017 study of 7- to 12-year-old soccer players in 4 European countries found that about 1 out of 10 concussions were caused by heading the ball.⁹ Comstock and colleageues¹⁰ found slightly higher numbers, roughly 25% to 30% (depending on gender), but 70% to 78% (again depending on gender) of those were caused by player-to-player contact rather than contact with the ball.

To date there has not been any meta-analytic review evaluating the cognitive and physical symptoms associated with heading in soccer. A recent review paper stated that the “current evidence seems insufficient to support a ban of heading in children’s football (soccer).”¹⁰ However, in December 2015 the US Soccer Federation included age-specific heading limitations. Players ages 10 years and under “shall not engage in heading, either in practices or in games” and players age 11 years and 12 years should have “limited heading in practice; maximum of 30 minutes of heading training per week, with no more than 15-20 headers per player, per week.”¹¹ US Soccer Federation officials acknowledged the limitations in the current science regarding heading in young soccer players but chose to err on the side of caution until further empirical evidence regarding the risks associated with repetitive heading is available.

The US Soccer Federation is also exploring other ways to reduce the incidence rate of concussions, including ensuring that the age-appropriate sized ball is used in practice and play, possible rule changes, evaluation of different playing surfaces, and equipment usage. To date, there is no strong evidence to support the use of mouth guards or helmets to reduce concussions in soccer. Additionally, the current data about the value of head impact sensors in soccer has not supported its widespread use.

Continue to: Finally, the issue of the prevalence...

Finally, the issue of the prevalence of chronic traumatic encephalopathy (CTE) in soccer players is beyond the scope of this article. The expert opinion from the 2017 US Soccer Federation, Major League Soccer (MLS), and National Women’s Soccer League (NWSL) conference concluded, “At present, no data exist that support that soccer participation is a risk factor for the development of neurodegenerative disease. Similarly, at this time, consistent with evidence discussed in the Berlin Concussion in Sport Group (CISG) Consensus Conference, our review suggests no causal relationship has been demonstrated between soccer and CTE pathology.”¹²

The more we know about concussions, both in general and those sustained during soccer play, the better we are able to diagnose and manage these injuries in our athletes. An important step is creating evidence-based protocols that evolve as our knowledge of concussions does as well. In April 2017, the US Soccer Federation, MLS, and the NWSL held a joint summit entitled, “Head Injury in Soccer: From Science to the Field” to address the current evidence-based science of concussions in soccer.⁸ An article discussing the findings of this meeting is forthcoming and will undoubtedly guide further development of concussion protocols for soccer players of all ages.

HEART

The physiologic demands of soccer place considerable stress on the cardiovascular system. Participation in training and competition is characterized by a combination of aerobic and anaerobic physiology with the typical athlete covering approximately 10 km over the course of the 90-minute match. The primary role of the heart and blood vessels is to supply the exercising skeletal muscle with oxygen and energy substrate and to clear the byproducts of metabolism. Among healthy athletes without cardiovascular disease, these processes are typically well tolerated and may be associated with beneficial cardiovascular adaptations over time. However, competitive soccer players are not completely immune to cardiovascular disease. Athletes across the age and competition spectrum may develop symptoms suggestive of underlying cardiovascular disease during play including exertional chest pain, inappropriate shortness of breath, palpitations, and syncope. These athletes require timely clinical evaluation. In extremely rare but high visibility cases, competitive soccer players may succumb to cardiac arrest on the pitch, underscoring the need for comprehensive emergency action plans (EAPs). We provide the practicing clinician with an overview of cardiovascular issues relevant to the competitive soccer athlete.

CARDIOVASCULAR ADAPTATIONS TO SPORT

The pressure (ie, repetitive surges in systemic blood pressure) and volume (ie, sustained increases in high cardiac output) challenges inherent in soccer participation place stress on the cardiovascular system. Healthy athletes across the age spectrum typically tolerate the hemodynamic stressors of participation without issues. Athletes that engage in training and competition over months to years often develop beneficial adaptations of the cardiovascular system that enhance on-field performance and contribute to optimal long-term health. Detailed discussion of how the heart and blood vessels respond to exercise training is beyond the scope of this article, but the interested reader is referred to several prior publications.^13,14 In brief, the heart of the healthy soccer athlete demonstrates the balanced mild chamber dilation and wall thickening characteristic of left ventricular eccentric remodeling. This form of exercise-induced cardiac remodeling facilitates maintenance of high stroke volume during exercise with minimal increases in cardiac work. In parallel, routine aerobic exercise training confers favorable changes in the systemic arterial system, which leads to reductions in age-associated ventricular stiffening and maintenance of healthy low blood pressure. It must be emphasized that the healthy heart muscle dilation and thickening that develop in response to sports participation, regardless of age, ethnicity, or gender, are relatively mild and should not be confused with common forms of heart muscle disease that may be seen in athletes at risk for adverse outcomes. In some situations, consultation with an extreme sports cardiologist may be required to differentiate exercise-induced remodeling from over heart muscle pathology.¹⁵

Continue to: THE SYMPTOMATIC ATHLETE...

THE SYMPTOMATIC ATHLETE

Any athlete presenting with symptoms suggestive of underlying cardiovascular disease should be withheld from training and competition until a comprehensive clinical evaluation has been completed. Common manifestations of underlying heart disease that occur in soccer players include exertional chest pain/pressure/tightness, shortness of breath that is out of proportion to workload, palpitations or the perception of irregular cardiac activity, and syncope. Chest discomfort, inappropriate shortness of breath, and palpitations that occur during training or competition should be managed with immediate removal from the playing field and prompt medical assessment. In many cases, thorough evaluation will involve collaboration between sports medicine and sports cardiology providers. Evaluations must be individualized on a case-by-case basis as tailored to the athlete’s presenting chief complaint and prior medical history. Most of these assessments will include a detailed medical history and physical examination, a 12-lead electrocardiogram (ECG), provocative exercise testing in a controlled environment, noninvasive cardiac imaging, and in some cases ambulatory rhythm monitoring. Uniformly, the athlete should be withheld from further training and competition until high-risk cardiovascular disease has been excluded. We refer the interested reader to a comprehensive discussion of symptom-based assessment of the athlete with suspected cardiovascular disease.¹⁶

Syncope (sudden and abrupt loss of consciousness with spontaneous neurologic recovery) is common among trained athletes. The vast majority of syncope is caused by “neurocardiogenic” mechanisms and carries a benign prognosis. Benign neurally-mediated syncope most often occurs outside of training and competition among athletes with heightened vagal tone and a predisposed susceptibility to triggers including pain, anxiety, emotional stimulation, and sudden postural change. Athletes who experience neurally-mediated syncope outside of training and competition routinely report a pre-event prodrome or aura that permits them to lower themselves to the ground, thereby avoiding injury. A distinct, but similarly benign and common, form of neurally-mediated fainting is post-exertional syncope. Here, fainting occurs within seconds of abrupt termination of exercise due to a rapid reduction cardiac preload and corollary cerebral blood supply. When either form of neurally-mediated syncope is suggested by a comprehensive medical history, normal physical examination, and a normal 12- lead ECG, further evaluation is unnecessary. However, the athlete and their coaching staff should be educated about avoidance tactics including hydration, dietary sodium supplementation, and avoidance of abrupt exercise termination as neutrally-mediated syncope tends to be recurrent without such measures. Fainting episodes that occur during training or competition that are not clearly post-exertional should be considered a medical emergency and should prompt comprehensive evaluation by a qualified cardiovascular specialist. Working closely with team physicians and athletic training staff, it is the responsibility of sports cardiologists to exclude potentially life-threatening forms of electrical, muscular, coronary, and valvular heart disease. Ideally, this evaluation should be conducted rapidly to avoid unnecessary delays in return to play.

CARDIAC ARREST AND SUDDEN DEATH

Numerous high-visibility cases of cardiac arrest on the soccer pitch have alerted the sporting community to the potential for these rare and potentially tragic events. Definitive incidence statistics defining the risk of cardiac arrest among soccer players are lacking. Data from the NCAA database suggest a sudden death incidence rate among collegiate male soccer athletes of approximately 1:24,000 athlete years.⁸ Similar data documenting incidence among female athletes and among those at lower (ie, youth level and high school) and higher (ie, professional) levels of play are unavailable. Underlying cardiovascular disease in the forms of heart muscle abnormalities (ie, genetic and acquired cardiomyopathy), coronary artery abnormalities (ie, genetic coronary anomalies and atherosclerotic coronary disease), valvular heart problems (ie, congenitally malformed aortic valves), and primary disturbances of the cardiac electrical system (ie, Wolf-Parkinson-White syndrome, long QT syndrome, etc.) explain a substantial percentage of on-pitch cardiac arrest. However, it is increasingly recognized that a significant minority of sudden cardiac deaths among athletes occur in the absence of attributable cardiovascular abnormality.¹⁷ Such cases, often referred to as “sudden unexplained death,” present unique challenges in the context of pre-participation screening, as they are undetectable and thus unpredictable.

Reduction of cardiac arrest and sudden death may best be accomplished through a combination of focused pre-participation screening and the development and implementation of a comprehensive EAP. Pre-participation involves the performance of a battery of tests prior to training and competition that are geared toward the detection of occult high-risk cardiovascular disease. Recommendations regarding pre-participation screening vary both across and within countries. Current US recommendations call for a focused medical history and physical examination prior to training and competition with consideration of the addition of a 12-lead ECG on a local level based on expertise and available resources.¹⁸ Conversely, current European guidelines including those endorsed by FIFA, suggest routine inclusion of a 12-lead ECG and in some cases, a transthoracic ECG.¹⁹ It must be emphasized that no screening approach has been confirmed to reduce the incidence of sudden death, and the decision to extend screening beyond the medical history and physical examination to include a 12-lead ECG or echocardiogram may come at the cost of increased false positive testing. In practice, decisions about how and when to screen are ideally made at a local level after consideration of medical and financial resources.²⁰

Continue to: Even the most comprehensive approach...

Even the most comprehensive approach to screening and evaluation of symptomatic athletes will not completely eliminate on-pitch cardiac arrest. Thus, all stakeholders that engage in the oversight of organized soccer must be committed to the development and implementation of an EAP.²¹ Key components of an effective EAP include the training of coaching staff, athletic trainers, and players in basic cardiopulmonary resuscitation, access to and training in the use of automated external defibrillators, and a triage/transport protocol that ensures timely access to advanced cardiac life support. Much like screening, emergency action planning involving these key core components must be developed and tailored locally. In the era of contemporary organized athletics, the absence of an EAP at any level of competition, from youth to professional leagues, is unacceptable. Effective EAPs must be developed, documented, and rehearsed at regular intervals. For the health and safety of competitive soccer players, as well as coaching staff and spectators, these steps are of critical importance.

HEAT

Heat-related illnesses can be serious and, at times, even life threatening. It is important for athletic staff and athletes to be well versed in the prevention, signs and symptoms, and treatment of heat-related illnesses in order to prevent serious and lasting injury. We aim to educate physicians about the prevention, recognition, and management of heat-related injury, and stress the importance of similarly educating athletes and coaching staff.

Exertional heat illnesses most often occur at temperatures >86°F, however they can occur at any temperature with heavy exertion.²² Signs and symptoms can be nonspecific early on, including weakness, fatigue, headache, nausea, and dizziness. Later signs can include imbalance, altered mentation, confusion, and behavior that is out of character such as irritability or aggression.²³ It is easy to see how the later signs can be confused for concussion in the right context. We cover the recognition and treatment of two common and serious heat-related illnesses: heat exhaustion and exertional heat stroke (EHS).

HEAT EXHAUSTION

Heat exhaustion occurs when an athlete cannot continue to exercise due to weakness and fatigue. While the exact mechanism is not well understood, it has been established that the combined effect of heat and dehydration have been proven to decrease exercise capacity and performance to a greater degree than either alone. The heat created by the body during exercise is 15 to 20 times greater than when at rest, and can increase core body temperature by 1°C every 5 minutes if no heat is lost, such as through sweating.²⁴ Additionally, when fluid deficits reach >3% to 5% of total body water, sweat production and skin blood flow decline, blunting the ability for the body to cool itself and causing progressive elevation of core body temperature if the athlete continues exerting him or herself. When fluid deficits reach 6% to 10%, cardiac output, sweat, and muscle blood flow decrease, likely leading to the symptoms seen with heat exhaustion: weakness, profound fatigue, and occasionally confusion and disorientation. Athletes with suspected heat exhaustion should be moved to a cooler area, laid down with legs elevated, and orally rehydrated. If they do not improve with oral rehydration, they may require intravenous fluids. The diagnosis of heat exhaustion hinges on a rectal temperature of <104°F; if >104°F the athlete should be presumed to have heat stroke, which will be addressed in the following paragraphs. Players can be cleared to return to play in mild cases within 24 to 48 hours with gradual increases in exercise intensity.²⁴

EXERTIONAL HEAT STROKE

EHS occurs when the body can no longer regulate the core body temperature and it rises to upwards of 104°F. In EHS, elevated core body temperature is associated with evidence of end organ dysfunction. The most easily identified on the playing field is likely central nervous system dysfunction, including irritability, confusion, irrational behavior, lethargy, dizziness, confusion, and even loss of consciousness. Temperature should be measured with rectal temperature only, as other methods of measurement have been shown to be consistently inaccurate.²² Heat stroke can be confused with exertional hyponatremia, heat exhaustion, or concussion, especially when core body temperature cannot be determined. However, EHS should always be the presumed cause of altered mentation when no rectal temperature is available because rapid cooling is critical to minimizing lasting effects. Morbidity and mortality are directly related to the length of time required to cool the athlete under 40°C (104°F).²⁴ Cooling should be completed on site prior to transport to a medical facility and is best achieved with submersion in an ice bath (ie, a kiddie pool or soaking tub full of ice and water).^22,25 If an ice bath is not available, ice bags should be applied to the neck axilla and groin and exchanged for fresh bags every 2 to 3 minutes.²² Ice bags have been shown to be inferior to whole body cooling, only cooling the athlete .04°C to .08°C/min compared to .15°C to .24°C/min with the ice bath.²⁴ All other tests should be delayed until cooling is achieved, unless they can be completed while cooling the athlete. The athlete can be removed from the ice bath once rectal temperatures reach <101°F to 102°F.²³ If the athlete returns to baseline after cooling, transportation to a medical facility may not be necessary. However, they should refrain from physical activity and heat exposure for at least 7 days and should be evaluated by a physician at that time. If all labs are normal and the athlete is asymptomatic, they can start progressive return to play under the direction of an athletic trainer or a sports medicine physician.²³

Continue to: HEAT-RELATED ILLNESS...

HEAT-RELATED ILLNESS

It is impossible to predict exactly which athletes will be most at risk for heat-related illness, so it is important to have a high degree of suspicion when environmental conditions are right. Athletes with recent illness, fever, or lack of sleep are at higher risk. Additional intrinsic risk factors include low fitness level, obesity, and inadequate hydration. Athletes who are highly competitive or motivated can be more likely to push through the early signs of illness or be reluctant to report symptoms.²³ Those with a history of exertional heat illness are more at risk for developing it again in the future.²³

The extrinsic risk factors for the development of heat-related illness are much easier to identify and modify in order to keep athletes safe. High temperature and high humidity conditions, heavy sun exposure, and exposure to similar conditions the preceding day put athletes at risk for exertional heat illness. Risks are even greater when the exercise is prolonged or intense with few breaks and access to hydration is limited.²³ Therefore, prevention of exertional heat illness is centered on these external risk factors.

Each team should have a heat policy as part of their EAP aimed at prevention and early recognition of heat-related illness. This policy should be shared with all athletes and coaches. The plan should be centered on acclimatization, activity modification, and early recognition and management as previously discussed. The US Soccer Federation “Recognize to Recover” Heat Guidelines suggest a 3-step process for appropriate activity modification:²²

1. Find the wet bulb globe temperature, either using a wet bulb globe thermometer or the temperature and humidity (Figure 1).

2. Find your regional weather category on the map (Figure 2).

3. Find your alert level and work to rest ratio recommendations (Figure 3).

Scheduled hydration breaks should be given as listed in Figure 3. Breaks of 4 minutes should be given for each 30 minutes of continuous practice or play. In a regulation 90-minute match, a hydration break should be given at 30 and 75 minutes (with half time at 45 minutes) at minimum. Athletes should be educated about where hydration can be accessed, and given unlimited access to hydration even outside of planned breaks.²²

Acclimatization to conditions is another integral part of preventing heat-related illness. It allows the body time to adapt to exercising in heat gradually, with a measured progression of exertion over the course of 10 to 14 days. The “Recognize to Recover” Heat Guidelines also provide guidance on acclimatization, and specifics can be found on the website.¹ Generally speaking, the warmest part of the day, usually between 11 AM and 4 PM, should be avoided for all training sessions, and length of practice and exertion should be gradually increased over 2 weeks.²²

In summary, appropriate acclimatization, hydration, activity modification, and education of athletes and staff are essential for the prevention of heat-related illness. Athletes and staff should understand the signs and symptoms of heat-related illness so that it can be recognized early and treated appropriately. If an athlete is altered in the heat and rectal temperature is >104°F or rectal temperature cannot be obtained, rapid cooling using an ice bath or ice bags is essential to prevent the morbidity and mortality associated with EHS. Above all, teams should have an explicit plan that includes protocols for acclimatization, activity modification, and all necessary equipment to prevent and treat heat-related illnesses should they occur, and ultimately keep athletes safe and healthy.

With an estimated 1.6 to 3.8 million sports-related mild traumatic brain injuries (ie, concussions) occurring annually in the United States,¹ there has been an appropriate increase in the focus on prevention and treatment of these injuries. For more than a decade the spotlight has been on concussions that occur in American football, but other sports have also had to examine the prevalence of concussions in their sport. This is certainly true for soccer.

There has been a steady increase in soccer participation in the United States. From 1973 to 2014 there was a 4-fold increase in high school boys and a 35-fold increase in high school girls playing soccer.² Currently, there are more than 3.7 million youth who play on teams under the supervision of the US Soccer Federation, the sport’s national governing body.³ With the growth of the sport, there has also been an intensified focus on injury prevention in soccer players, including concussive brain injuries.

A recent study examined injury rates in high school soccer players and noted that concussion is the second most common injury (17.9%), after ligament sprains (29.7%).⁴ The overall injury rate was 2.06 per 1000 athletic exposures (AEs [defined as participation in practice or game play]), but higher in games (4.42 per 1000 AEs) than during practices (1.05 per 1000 AEs). The overall concussion rate was 0.36 per 1000 AEs.⁴

Most concussions (54.8%) resulted in missing play between 1 to 3 weeks, but a sizeable portion of the athletes (14.9%) were out of play for more than 3 weeks. Additionally, 10.7% of all medical disqualifications were due to concussive injuries. Khodaee and colleagues⁴ found no statistically significant difference in concussion rates between male and female soccer players over the 9-year period of time that they examined, however previous studies have found higher rates in female athletes.⁵

In soccer, as in other sports, there is a concern about both the adequate recognition of concussions during practice and play and the underreporting of concussions by athletes. The US Soccer Federation has taken a proactive stance on addressing concussion in youth soccer by developing the “Recognize to Recover” program.⁶ Recognize to Recover is the US Soccer Federation’s “comprehensive player health and safety program aimed at promoting safe play and reducing injuries in soccer players of all ages.” The website provides an educational video geared toward players, along with links to concussion assessment tools, the US Soccer Federation Concussion Protocol, and US Soccer Federation-Centers for Disease Control fact sheets for athletes, parents, and coaches.⁶

Continue to: A challenge for all sports...

A challenge for all sports is allowing adequate evaluation of a suspected concussion by properly trained healthcare professionals. The 2017 Berlin Concussion in Sport Group position paper stated, “when a concussion is suspected, the athlete should be removed from the sporting environment and a multimodal assessment should be conducted in standardized fashion (eg, Sport Concussion Assessment Tool- 5th edition). Sporting bodies should allow adequate time to conduct this evaluation.”⁷ However, the International Federation of Football Association (FIFA) rules limit substitutions to 3 over the course of the game, which can make a thorough evaluation of players difficult as trainers and coaches are under increased pressure to quickly determine whether to use one of their valuable substitutions. Fortunately, the National Collegiate Athletic Association (NCAA) soccer has mitigated this issue by allowing unlimited substitutions during matches, and high school teams generally follow similar rules.

One of the goals of any safety education program is not only to raise the awareness of the signs and symptoms of concussion by all those involved in the sport, but also to increase the number of athletes who self-report their symptoms and decrease those who hide any possible concussions. A study found that a majority (58.6%) of middle school soccer players continued to play while experiencing concussion symptoms.⁵ However, in a very recent (not yet published) study, 92% of US Soccer Federation players reported that they did seek out a medical evaluation for their concussion.⁸ This is certainly a positive sign and further research needs to clarify what methods of education or training will maintain this level of self-reporting in soccer players.

There has also been an increased focus on understanding the mechanism of injury of concussions. In soccer, concussions can occur from player-to-player contact, contact with the player surface, contact with playing apparatus (eg, goal posts) and non-contact mechanisms. While there has been a focus on concussions from heading the ball, player-to-player contact is the most common cause of concussions. A 2017 study of 7- to 12-year-old soccer players in 4 European countries found that about 1 out of 10 concussions were caused by heading the ball.⁹ Comstock and colleageues¹⁰ found slightly higher numbers, roughly 25% to 30% (depending on gender), but 70% to 78% (again depending on gender) of those were caused by player-to-player contact rather than contact with the ball.

To date there has not been any meta-analytic review evaluating the cognitive and physical symptoms associated with heading in soccer. A recent review paper stated that the “current evidence seems insufficient to support a ban of heading in children’s football (soccer).”¹⁰ However, in December 2015 the US Soccer Federation included age-specific heading limitations. Players ages 10 years and under “shall not engage in heading, either in practices or in games” and players age 11 years and 12 years should have “limited heading in practice; maximum of 30 minutes of heading training per week, with no more than 15-20 headers per player, per week.”¹¹ US Soccer Federation officials acknowledged the limitations in the current science regarding heading in young soccer players but chose to err on the side of caution until further empirical evidence regarding the risks associated with repetitive heading is available.

The US Soccer Federation is also exploring other ways to reduce the incidence rate of concussions, including ensuring that the age-appropriate sized ball is used in practice and play, possible rule changes, evaluation of different playing surfaces, and equipment usage. To date, there is no strong evidence to support the use of mouth guards or helmets to reduce concussions in soccer. Additionally, the current data about the value of head impact sensors in soccer has not supported its widespread use.

Continue to: Finally, the issue of the prevalence...

Finally, the issue of the prevalence of chronic traumatic encephalopathy (CTE) in soccer players is beyond the scope of this article. The expert opinion from the 2017 US Soccer Federation, Major League Soccer (MLS), and National Women’s Soccer League (NWSL) conference concluded, “At present, no data exist that support that soccer participation is a risk factor for the development of neurodegenerative disease. Similarly, at this time, consistent with evidence discussed in the Berlin Concussion in Sport Group (CISG) Consensus Conference, our review suggests no causal relationship has been demonstrated between soccer and CTE pathology.”¹²

The more we know about concussions, both in general and those sustained during soccer play, the better we are able to diagnose and manage these injuries in our athletes. An important step is creating evidence-based protocols that evolve as our knowledge of concussions does as well. In April 2017, the US Soccer Federation, MLS, and the NWSL held a joint summit entitled, “Head Injury in Soccer: From Science to the Field” to address the current evidence-based science of concussions in soccer.⁸ An article discussing the findings of this meeting is forthcoming and will undoubtedly guide further development of concussion protocols for soccer players of all ages.

HEART

The physiologic demands of soccer place considerable stress on the cardiovascular system. Participation in training and competition is characterized by a combination of aerobic and anaerobic physiology with the typical athlete covering approximately 10 km over the course of the 90-minute match. The primary role of the heart and blood vessels is to supply the exercising skeletal muscle with oxygen and energy substrate and to clear the byproducts of metabolism. Among healthy athletes without cardiovascular disease, these processes are typically well tolerated and may be associated with beneficial cardiovascular adaptations over time. However, competitive soccer players are not completely immune to cardiovascular disease. Athletes across the age and competition spectrum may develop symptoms suggestive of underlying cardiovascular disease during play including exertional chest pain, inappropriate shortness of breath, palpitations, and syncope. These athletes require timely clinical evaluation. In extremely rare but high visibility cases, competitive soccer players may succumb to cardiac arrest on the pitch, underscoring the need for comprehensive emergency action plans (EAPs). We provide the practicing clinician with an overview of cardiovascular issues relevant to the competitive soccer athlete.

CARDIOVASCULAR ADAPTATIONS TO SPORT

The pressure (ie, repetitive surges in systemic blood pressure) and volume (ie, sustained increases in high cardiac output) challenges inherent in soccer participation place stress on the cardiovascular system. Healthy athletes across the age spectrum typically tolerate the hemodynamic stressors of participation without issues. Athletes that engage in training and competition over months to years often develop beneficial adaptations of the cardiovascular system that enhance on-field performance and contribute to optimal long-term health. Detailed discussion of how the heart and blood vessels respond to exercise training is beyond the scope of this article, but the interested reader is referred to several prior publications.^13,14 In brief, the heart of the healthy soccer athlete demonstrates the balanced mild chamber dilation and wall thickening characteristic of left ventricular eccentric remodeling. This form of exercise-induced cardiac remodeling facilitates maintenance of high stroke volume during exercise with minimal increases in cardiac work. In parallel, routine aerobic exercise training confers favorable changes in the systemic arterial system, which leads to reductions in age-associated ventricular stiffening and maintenance of healthy low blood pressure. It must be emphasized that the healthy heart muscle dilation and thickening that develop in response to sports participation, regardless of age, ethnicity, or gender, are relatively mild and should not be confused with common forms of heart muscle disease that may be seen in athletes at risk for adverse outcomes. In some situations, consultation with an extreme sports cardiologist may be required to differentiate exercise-induced remodeling from over heart muscle pathology.¹⁵

Continue to: THE SYMPTOMATIC ATHLETE...

THE SYMPTOMATIC ATHLETE

Any athlete presenting with symptoms suggestive of underlying cardiovascular disease should be withheld from training and competition until a comprehensive clinical evaluation has been completed. Common manifestations of underlying heart disease that occur in soccer players include exertional chest pain/pressure/tightness, shortness of breath that is out of proportion to workload, palpitations or the perception of irregular cardiac activity, and syncope. Chest discomfort, inappropriate shortness of breath, and palpitations that occur during training or competition should be managed with immediate removal from the playing field and prompt medical assessment. In many cases, thorough evaluation will involve collaboration between sports medicine and sports cardiology providers. Evaluations must be individualized on a case-by-case basis as tailored to the athlete’s presenting chief complaint and prior medical history. Most of these assessments will include a detailed medical history and physical examination, a 12-lead electrocardiogram (ECG), provocative exercise testing in a controlled environment, noninvasive cardiac imaging, and in some cases ambulatory rhythm monitoring. Uniformly, the athlete should be withheld from further training and competition until high-risk cardiovascular disease has been excluded. We refer the interested reader to a comprehensive discussion of symptom-based assessment of the athlete with suspected cardiovascular disease.¹⁶

Syncope (sudden and abrupt loss of consciousness with spontaneous neurologic recovery) is common among trained athletes. The vast majority of syncope is caused by “neurocardiogenic” mechanisms and carries a benign prognosis. Benign neurally-mediated syncope most often occurs outside of training and competition among athletes with heightened vagal tone and a predisposed susceptibility to triggers including pain, anxiety, emotional stimulation, and sudden postural change. Athletes who experience neurally-mediated syncope outside of training and competition routinely report a pre-event prodrome or aura that permits them to lower themselves to the ground, thereby avoiding injury. A distinct, but similarly benign and common, form of neurally-mediated fainting is post-exertional syncope. Here, fainting occurs within seconds of abrupt termination of exercise due to a rapid reduction cardiac preload and corollary cerebral blood supply. When either form of neurally-mediated syncope is suggested by a comprehensive medical history, normal physical examination, and a normal 12- lead ECG, further evaluation is unnecessary. However, the athlete and their coaching staff should be educated about avoidance tactics including hydration, dietary sodium supplementation, and avoidance of abrupt exercise termination as neutrally-mediated syncope tends to be recurrent without such measures. Fainting episodes that occur during training or competition that are not clearly post-exertional should be considered a medical emergency and should prompt comprehensive evaluation by a qualified cardiovascular specialist. Working closely with team physicians and athletic training staff, it is the responsibility of sports cardiologists to exclude potentially life-threatening forms of electrical, muscular, coronary, and valvular heart disease. Ideally, this evaluation should be conducted rapidly to avoid unnecessary delays in return to play.

CARDIAC ARREST AND SUDDEN DEATH

Numerous high-visibility cases of cardiac arrest on the soccer pitch have alerted the sporting community to the potential for these rare and potentially tragic events. Definitive incidence statistics defining the risk of cardiac arrest among soccer players are lacking. Data from the NCAA database suggest a sudden death incidence rate among collegiate male soccer athletes of approximately 1:24,000 athlete years.⁸ Similar data documenting incidence among female athletes and among those at lower (ie, youth level and high school) and higher (ie, professional) levels of play are unavailable. Underlying cardiovascular disease in the forms of heart muscle abnormalities (ie, genetic and acquired cardiomyopathy), coronary artery abnormalities (ie, genetic coronary anomalies and atherosclerotic coronary disease), valvular heart problems (ie, congenitally malformed aortic valves), and primary disturbances of the cardiac electrical system (ie, Wolf-Parkinson-White syndrome, long QT syndrome, etc.) explain a substantial percentage of on-pitch cardiac arrest. However, it is increasingly recognized that a significant minority of sudden cardiac deaths among athletes occur in the absence of attributable cardiovascular abnormality.¹⁷ Such cases, often referred to as “sudden unexplained death,” present unique challenges in the context of pre-participation screening, as they are undetectable and thus unpredictable.

Reduction of cardiac arrest and sudden death may best be accomplished through a combination of focused pre-participation screening and the development and implementation of a comprehensive EAP. Pre-participation involves the performance of a battery of tests prior to training and competition that are geared toward the detection of occult high-risk cardiovascular disease. Recommendations regarding pre-participation screening vary both across and within countries. Current US recommendations call for a focused medical history and physical examination prior to training and competition with consideration of the addition of a 12-lead ECG on a local level based on expertise and available resources.¹⁸ Conversely, current European guidelines including those endorsed by FIFA, suggest routine inclusion of a 12-lead ECG and in some cases, a transthoracic ECG.¹⁹ It must be emphasized that no screening approach has been confirmed to reduce the incidence of sudden death, and the decision to extend screening beyond the medical history and physical examination to include a 12-lead ECG or echocardiogram may come at the cost of increased false positive testing. In practice, decisions about how and when to screen are ideally made at a local level after consideration of medical and financial resources.²⁰

Continue to: Even the most comprehensive approach...

Even the most comprehensive approach to screening and evaluation of symptomatic athletes will not completely eliminate on-pitch cardiac arrest. Thus, all stakeholders that engage in the oversight of organized soccer must be committed to the development and implementation of an EAP.²¹ Key components of an effective EAP include the training of coaching staff, athletic trainers, and players in basic cardiopulmonary resuscitation, access to and training in the use of automated external defibrillators, and a triage/transport protocol that ensures timely access to advanced cardiac life support. Much like screening, emergency action planning involving these key core components must be developed and tailored locally. In the era of contemporary organized athletics, the absence of an EAP at any level of competition, from youth to professional leagues, is unacceptable. Effective EAPs must be developed, documented, and rehearsed at regular intervals. For the health and safety of competitive soccer players, as well as coaching staff and spectators, these steps are of critical importance.

HEAT

Heat-related illnesses can be serious and, at times, even life threatening. It is important for athletic staff and athletes to be well versed in the prevention, signs and symptoms, and treatment of heat-related illnesses in order to prevent serious and lasting injury. We aim to educate physicians about the prevention, recognition, and management of heat-related injury, and stress the importance of similarly educating athletes and coaching staff.

Exertional heat illnesses most often occur at temperatures >86°F, however they can occur at any temperature with heavy exertion.²² Signs and symptoms can be nonspecific early on, including weakness, fatigue, headache, nausea, and dizziness. Later signs can include imbalance, altered mentation, confusion, and behavior that is out of character such as irritability or aggression.²³ It is easy to see how the later signs can be confused for concussion in the right context. We cover the recognition and treatment of two common and serious heat-related illnesses: heat exhaustion and exertional heat stroke (EHS).

HEAT EXHAUSTION

Heat exhaustion occurs when an athlete cannot continue to exercise due to weakness and fatigue. While the exact mechanism is not well understood, it has been established that the combined effect of heat and dehydration have been proven to decrease exercise capacity and performance to a greater degree than either alone. The heat created by the body during exercise is 15 to 20 times greater than when at rest, and can increase core body temperature by 1°C every 5 minutes if no heat is lost, such as through sweating.²⁴ Additionally, when fluid deficits reach >3% to 5% of total body water, sweat production and skin blood flow decline, blunting the ability for the body to cool itself and causing progressive elevation of core body temperature if the athlete continues exerting him or herself. When fluid deficits reach 6% to 10%, cardiac output, sweat, and muscle blood flow decrease, likely leading to the symptoms seen with heat exhaustion: weakness, profound fatigue, and occasionally confusion and disorientation. Athletes with suspected heat exhaustion should be moved to a cooler area, laid down with legs elevated, and orally rehydrated. If they do not improve with oral rehydration, they may require intravenous fluids. The diagnosis of heat exhaustion hinges on a rectal temperature of <104°F; if >104°F the athlete should be presumed to have heat stroke, which will be addressed in the following paragraphs. Players can be cleared to return to play in mild cases within 24 to 48 hours with gradual increases in exercise intensity.²⁴

EXERTIONAL HEAT STROKE

EHS occurs when the body can no longer regulate the core body temperature and it rises to upwards of 104°F. In EHS, elevated core body temperature is associated with evidence of end organ dysfunction. The most easily identified on the playing field is likely central nervous system dysfunction, including irritability, confusion, irrational behavior, lethargy, dizziness, confusion, and even loss of consciousness. Temperature should be measured with rectal temperature only, as other methods of measurement have been shown to be consistently inaccurate.²² Heat stroke can be confused with exertional hyponatremia, heat exhaustion, or concussion, especially when core body temperature cannot be determined. However, EHS should always be the presumed cause of altered mentation when no rectal temperature is available because rapid cooling is critical to minimizing lasting effects. Morbidity and mortality are directly related to the length of time required to cool the athlete under 40°C (104°F).²⁴ Cooling should be completed on site prior to transport to a medical facility and is best achieved with submersion in an ice bath (ie, a kiddie pool or soaking tub full of ice and water).^22,25 If an ice bath is not available, ice bags should be applied to the neck axilla and groin and exchanged for fresh bags every 2 to 3 minutes.²² Ice bags have been shown to be inferior to whole body cooling, only cooling the athlete .04°C to .08°C/min compared to .15°C to .24°C/min with the ice bath.²⁴ All other tests should be delayed until cooling is achieved, unless they can be completed while cooling the athlete. The athlete can be removed from the ice bath once rectal temperatures reach <101°F to 102°F.²³ If the athlete returns to baseline after cooling, transportation to a medical facility may not be necessary. However, they should refrain from physical activity and heat exposure for at least 7 days and should be evaluated by a physician at that time. If all labs are normal and the athlete is asymptomatic, they can start progressive return to play under the direction of an athletic trainer or a sports medicine physician.²³

Continue to: HEAT-RELATED ILLNESS...

HEAT-RELATED ILLNESS

It is impossible to predict exactly which athletes will be most at risk for heat-related illness, so it is important to have a high degree of suspicion when environmental conditions are right. Athletes with recent illness, fever, or lack of sleep are at higher risk. Additional intrinsic risk factors include low fitness level, obesity, and inadequate hydration. Athletes who are highly competitive or motivated can be more likely to push through the early signs of illness or be reluctant to report symptoms.²³ Those with a history of exertional heat illness are more at risk for developing it again in the future.²³

The extrinsic risk factors for the development of heat-related illness are much easier to identify and modify in order to keep athletes safe. High temperature and high humidity conditions, heavy sun exposure, and exposure to similar conditions the preceding day put athletes at risk for exertional heat illness. Risks are even greater when the exercise is prolonged or intense with few breaks and access to hydration is limited.²³ Therefore, prevention of exertional heat illness is centered on these external risk factors.

Each team should have a heat policy as part of their EAP aimed at prevention and early recognition of heat-related illness. This policy should be shared with all athletes and coaches. The plan should be centered on acclimatization, activity modification, and early recognition and management as previously discussed. The US Soccer Federation “Recognize to Recover” Heat Guidelines suggest a 3-step process for appropriate activity modification:²²

1. Find the wet bulb globe temperature, either using a wet bulb globe thermometer or the temperature and humidity (Figure 1).

2. Find your regional weather category on the map (Figure 2).

3. Find your alert level and work to rest ratio recommendations (Figure 3).

Scheduled hydration breaks should be given as listed in Figure 3. Breaks of 4 minutes should be given for each 30 minutes of continuous practice or play. In a regulation 90-minute match, a hydration break should be given at 30 and 75 minutes (with half time at 45 minutes) at minimum. Athletes should be educated about where hydration can be accessed, and given unlimited access to hydration even outside of planned breaks.²²

Acclimatization to conditions is another integral part of preventing heat-related illness. It allows the body time to adapt to exercising in heat gradually, with a measured progression of exertion over the course of 10 to 14 days. The “Recognize to Recover” Heat Guidelines also provide guidance on acclimatization, and specifics can be found on the website.¹ Generally speaking, the warmest part of the day, usually between 11 AM and 4 PM, should be avoided for all training sessions, and length of practice and exertion should be gradually increased over 2 weeks.²²

In summary, appropriate acclimatization, hydration, activity modification, and education of athletes and staff are essential for the prevention of heat-related illness. Athletes and staff should understand the signs and symptoms of heat-related illness so that it can be recognized early and treated appropriately. If an athlete is altered in the heat and rectal temperature is >104°F or rectal temperature cannot be obtained, rapid cooling using an ice bath or ice bags is essential to prevent the morbidity and mortality associated with EHS. Above all, teams should have an explicit plan that includes protocols for acclimatization, activity modification, and all necessary equipment to prevent and treat heat-related illnesses should they occur, and ultimately keep athletes safe and healthy.

The purpose of this study is to detail the postoperative complications that occur following TSA using a large national database. Specifically, our goals are to determine the incidence and types of complications after shoulder arthroplasty, determine the patient factors that are associated with these complications, and evaluate the effects of these complications on postoperative in-hospital mortality and length of stay (LOS). Our hypothesis is that there would be a correlation between specific patient factors and complications and that these complications would adversely correlate to patient postoperative outcomes.

METHODS

DESIGN

We conducted a retrospective analysis of TSAs captured by the Nationwide Inpatient Sample (NIS) database between 2006 and 2010. The NIS is the largest all-payer inpatient database that is currently available to the public in the United States.⁷

The NIS is a part of the Healthcare Cost and Utilization Project funded by the Agency for Healthcare Research and Quality (AHRQ) and the US Department of Health and Human Services. The NIS database is designed to approximate a 20% sample of US hospitals and the patients they serve, including community, academic, general, and specialty-specific hospitals such as orthopedic hospitals.⁷ The 2010 update of the NIS database contains discharge data from 1051 hospitals across 45 states, with a representative sample of >39 million inpatient hospital stays.⁷ The NIS database and its data sources have been independently validated and assessed for quality each year since 1988.⁸Furthermore, comparative analysis of multiple database elements and distributions has been validated against standard norms, including the National Hospital Discharge Survey.⁹ The NIS database has been used in numerous published studies.^2,10,11

PATIENT SELECTION

The yearly NIS databases from 2006 to 2010 were compiled. Patients aged ≥40 years who underwent a TSA were identified using the International Classification of Diseases, 9th Revision (ICD-9), procedural code 81.80. Exclusion criteria were patients with a primary or a secondary diagnosis of humeral or scapular fracture, chronic osteomyelitis, rheumatologic diseases, or evidence of concurrent malignancy (Figure 1).

Native to NIS are patient demographics, including age, sex, and race. Patient comorbidities as described by Elixhauser and colleagues¹² are also included in the database.

Continue to: OUTCOMES...

OUTCOMES

The primary outcome of this study was a description of the type and frequency of postoperative complications of TSA. To conduct this analysis, we queried the TSA cohort for specific ICD-9 codes representing acute cardiac, central nervous system, infectious, gastrointestinal, genitourinary, postoperative shock, renal, respiratory, surgical, vascular, and wound complications. The ICD-9 codes used to identify complications were modeled according to previous literature on various surgical applications and were further parsed to reflect only acute postoperative diagnoses^13-15(see the Appendix for the comprehensive list of ICD-9 codes).

Two additional outcomes were analyzed, including postoperative mortality and LOS. Postoperative mortality was defined as death occurring prior to discharge. We calculated the average LOS among the complication and the noncomplication cohort.

STATISTICAL ANALYSIS

Patient demographics and target outcomes of the study were analyzed by frequency distribution. Where applicable, the chi-square and the Student’s t tests were used to confirm the statistical difference for dichotomous and continuous variables, respectively. Multivariate regressions were performed after controlling for possible clustering of the data using a generalized estimating equation following a previous analytical methodology.^16-20 The results are reported with odds ratios and 95% confidence intervals where applicable, all statistical tests with P ≤ 0.05 were considered to be significant, and all statistical tests were two-sided. We conducted all analyses using SAS, version 9.2 (SAS Institute).

RESULTS

From 2006 to 2010, a weighted sample of 141,973 patients was found to undergo a TSA. After applying our inclusion and exclusion criteria, our study cohort consisted of 125,766 patients (Figure 1).

Continue to: OVERALL TSA COHORT DEMOGRAPHICS...

OVERALL TSA COHORT DEMOGRAPHICS

The average age of the TSA cohort was 69.4 years (standard deviation [SD], 21.20), and 54.1% were females. The cohort had significant comorbidities, with 83.3% of them having at least 1 comorbidity at the time of surgery. Specifically, 31.3% of the patients had 1 comorbidity, 26.5% had 2 comorbidities, and 25.4% had ≥3 comorbidities. Hypertension was the most common comorbidity present in 66.2% of patients, and diabetes was the second most common comorbidity with a prevalence of 16.8%.

COMPLICATION COHORT DEMOGRAPHICS

An overall postoperative complication rate of 6.7% (weighted sample of 8457 patients) was noted in the overall TSA cohort. The TSA cohort was dichotomized into patients who suffered at least 1 complication (weighted, n = 8457) and patients undergoing routine TSAs (weighted, n = 117,308). The average age was significantly higher in the complication vs routine cohort (71.38 vs 69.27 years, P < 0.0001). Similarly, there were significantly more comorbidities (2.51 vs 1.71, P < 0.0001) in the complication cohort.

COMPLICATIONS

We noted a complication rate of 6.7% (weighted sample of 8457 patients). A single complication was noted in 5% of these patients, whereas 1.3% and 0.4% of the patients had 2 and ≥3 complications, respectively. Respiratory abnormalities (2.9%), acute renal failure (0.8%), and cardiac complications (0.8%) were the most prevalent complications after TSA. The list of complications is detailed in Figure 2. Logistic regression analysis of patient characteristics predicting complications showed that advanced age (odds ratio [OR], 2.1 in those aged ≥85 years) and increasing number of comorbidities (≥3; OR, 3.5) were most significant in predicting complications (all P < 0.0001) (Figure 3). Despite the ubiquity of hypertension in this patient population, it was not a significant predictor of complication (OR, 0.9); in contrast, pulmonary disorders (OR, 5.1) and fluid and electrolyte disorders (4.0) were most strongly associated with the development of a postoperative complication after surgery (Figure 4).

EFFECT OF COMPLICATIONS ON LOS

The average length of hospitalization was 2.3 days (95% confidence interval, 2.22-2.25) among the entire cohort. The average LOS was longer in the complication cohort (3.9 days) than in patients who did not have a complication (2.1 days, P < 0.0001). Of the specific complications noted, hemodynamic shock (11.8 days); infectious, most commonly pneumonia (7.6 days); and vascular complications (6.9 days) were associated with the longest hospitalizations. This result is summarized in Figure 5.

MORTALITY

An overall postoperative (in-house) mortality rate of 0.07% was noted (weighted, n = 88). Comparison between the patient cohort that died vs those who survived TSA resulted in significant differences in the rates of complications. Complications that were most significantly different between the cohorts included cardiac (60.47% vs 0.75%, P < 0.0001), postoperative shock (26.61% vs 0.04%, P < 0.0001), and respiratory complications (43.1% vs 2.8%, P < 0.0001). It is important to note that the overall rate of postoperative shock was exceedingly low in the TSA cohort, but it was highly prevalent in the mortality cohort, occurring in 26.61% of patients. A summary of the mortality statistics is presented in Figure 6.

Continue to: DISCUSSION...

DISCUSSION

TSA continues to be associated with high levels of satisfaction;¹ as a result, its incidence is increasing.² As our understanding and efficiency improves nationally, it is imperative that we determine the short-term and longer-term outcomes and complications. In addition, the factors that may affect prognosis must be elucidated to provide a more individualized and effective standard of care. To date, most of the outcome studies of TSA have evaluated long-term outcomes and specific implant-related complications.^1,5,6,21,22 Our intent was to evaluate the complications that occur in the postoperative period and their effect on unique “patient care” outcomes. With knowledge of these complications and the predisposing factors, we can better assess patients, risk-stratify, and provide appropriate guidelines.

We noted that complications occurring after TSA are not uncommon, with >6% of patients suffering a postoperative complication. In this study, the number of complications noted was associated with worse patient outcomes. In addition, we noted that patients undergoing a TSA have a significant burden of comorbidities; however, hematologic and fluid disorders (eg, iron deficiency anemia, pulmonary circulatory disorders, and fluid imbalances) were most important in predicting postoperative complications.

Increased LOS in the hospital after TSA was associated with the occurrence of complications. Of all noted complications, shock and infectious and vascular complications led to the longest hospitalizations. Hospital-acquired pneumonia was the most common infectious etiology, while pulmonary embolism and deep vein thrombosis were the most consistent vascular complications. Although seldom studied in the TSA population, a similar finding has been noted in patients after THA. O’Malley and colleagues,²³ using the American College of Surgeon’s National Surgical Quality Improvement Program database, identified independent factors that were associated with complications and average prolonged LOS. They noted that the occurrence of major complications was associated with a prolonged LOS. Some, but not all the major complications, included organ space infection, cardiac events, pneumonia, and venous thromboembolic events.²³ Therefore, attempts to limit the amount of time spent in hospitals and control the associated costs must focus on managing the incidence of complications.

Postoperative mortality after TSA was uncommon, occurring in 0.07% of the patients in this study. The low incidence of mortality noted in this study is probably related to the fact that our data represent mortality, whereas in the hospital and, unlike most mortality studies, it does not account for patient demise that may occur in the months after surgery. Other reports have noted that mortality occurs in <1.5% of these patients.^24-28 Singh and colleagues²⁵ observed in their evaluation of perioperative mortality after TSA a mortality rate of 0.8% with 90 days after 4380 shoulder replacements performed at their institution. Using multivariate analysis, they were able to identify associations between mortality and increasing American Society of Anesthesiology (ASA) class and Charlson Comorbidity Index. These results in relation to ours would indicate that the majority of patients who die after shoulder arthroplasty do so after initial discharge. Although we could not determine a causal relationship between mortality and patient comorbidities, we noted that certain complications strongly correlated with mortality. In patients who died, there was a relatively high incidence of cardiac (60.5%) and respiratory (43.1%) complications. Similarly, although postoperative shock was almost nonexistent in the patients who survived surgery (0.04%), it was much more common in the patients who suffered mortality (26.6%).

This study is not without limitations. Data were extracted from a national database, therefore precluding the inclusion of specific details of surgery and functional assessment. Inherent to ICD-9 coding, we were unable to assess the exact detail and severity of complications. For instance, we cannot be certain what criteria were used to define “acute renal failure” for each patient. This study is retrospective in nature and therefore adequate randomization and standardization of patients is not possible. Similarly, the nature of the database may not allow for exacting our inclusion and exclusion criteria. However, the large sample size of the patient population lessens the chance of potential biases and type 2 errors. Prior to October 2010, reverse shoulder arthroplasty was coded under the ICD-9procedural code 81.80 as TSA. Therefore, there is some overlap between TSA and reverse shoulder arthroplasty in our data. Reverse shoulder arthroplasty is now coded under ICD-9 procedural code 81.88. It is possible that results may differ if reverse shoulder arthroplasty were excluded from our patient cohort. This can be an area of future research.

CONCLUSION

Although much is known about the long-term hardware and functional complications after TSA, in this study, we have attempted to broaden the understanding of perioperative complications and the associated sequelae. Complications are common after TSA surgery and are related to adverse outcomes. In the setting of healthcare changes, the surgeon and the patient must understand the cause, types, incidence, and outcomes of medical and surgical complications after surgery. This allows for more accurate “standard of care” metrics. Further large-volume multicenter studies are needed to gain further insight into the short- and long-term outcomes of TSA.