1. Soccer: Staying on the Field Andrew Getzin, MD Clinical Director Sports Medicine and Athletic Performance agetzin@cayugamed.org www.cayugamed.org/sportsmedicine

2. Overview Injury Data Hamstring strains Injury prevention

3. Statistics Most popular sport in the world 200,000 professional soccer players 240 million amateur players

4. Nature of Soccer Contact sport Low static- High Dynamic High-moderate intensity sport –Physically demanding Aerobic –Running: long-distance and sprinting

5. Injury Incidence- ER visits 1990-2003, 2-18 years old 1,597,528 injuries over 13 years Mean age = 13.2, Gender = 58.6% male Body parts: –Wrist/hand 20.3%, ankle 18.2%, knee 11.4% Diagnosis: –Sprain/strain 35.9%, contusion/abrasion 24.1%, fracture 23.2% Leininger, AJSM 2007

6. Injury Incidence- US High Schools 2.39/1000 hours of participation –Higher rate during competition (4.77) than practice (1.37) Diagnoses –Ligament sprains 26.8%, muscle strains 17.9%, contusion 13.8%, concussion 10.8% Body part –Ankle 23.4%, knee 18.7%, head/face 13.7%, thigh/upper leg 13.1% Yard. AJSM 2008

7. Risk Factors Increasing age Female gender (schmidt-Olsen 1991, Concussion and ACLs, Putukian, 2002) Prior injury- i.e. ankle (Soderman, 2001, Emery, 2006) Position?

8. Injury Rates Overall injury rates –Higher than American Football, basketball, field hockey, rugby (Wong 2005) Concussion rate –Similar to American football, ice hockey (Al-Kashmiri, 2006)

9. Hamstring Anatomy Muscles –Semimembranosus –Semitendinosus –Long and short head of biceps femoris –Hamstring portion of adductor magnus Originate from the pelvis and insert distally into the knee

10. Hamstring Mechanism of Injury Sprinting or Jumping Usually occurs with eccentric loading- slowing down Poor flexibility? Strength imbalance 62% occur in competition, 32% in practice Increased risk at end of halves and with prolonged training 34% recurrence rate

11. Clinical Presentation and History Sudden onset of pain in posterior thigh May or may not have a pop Loss of strength Transient sciatica

12. Physical Exam Area slightly swollen, tender, may or may not have ecchymosis Important to palpate hamstring for possible defect or avulsion Passive knee extension and hip flexion increased pain The more proximal to the origin the injury- the longer the return to play

13. Taking Shoes Off Test Zeren. Clin J Sports Med 2006

14. Imaging Limited role for plain x-ray, can help exclude avulsion fracture MRI helpful with prognosis, often serial MRI ?worth the cost

15. Early Treatment: day 0-7, Inflammatory phase The correct early treatment for an acute hamstring strain includes: A: RICE (rest, ice, compression, elevation) B: Immobilization C: Advil and/or Tylenol as needed D: all of the above

16. Sub-acute Treatment All are appropriate sub-acute treatments except: A.Initiate range of motion exercises a few days after the injury B.Progress to jogging when ready C.Gradually initiate eccentric loading D.Play X-box all day while resting your hamstring

17. Hamstring Rehab 24 athletes with acute hamstring strain Stretching and strengthening group Progressive agility and trunk stabilization group RTP 37.4 vs. 22.2 days Sherry and Best. J Ortho Sports PT 2004

18. Chance of Recurrence After Return from Injury- Australian Football League Orchard, John; Best, Thomas M. Clinical Journal of Sport Medicine. 2002.

19. Hamstring Return to Soccer When is the best time to return to play? A.When Full Range of Motion and symmetrical strength is achieved B.When there is no pain at full practice C.The day before the championship game D.Other

20. Hamstring Injury Prevention Askling. Scand J Med Sports 2003 30 players from Sweden premier division 10/15 hamstring injuries in the control group 3/15 hamstring injuries in intervention Intervention improved running speed

21. The PEP Program: Prevent Injury And Enhance Performance Decrease in ACL Injuries in trained Female athletes 2001: 88% 2002: 78% Mandelbaum,. Am J Sports Med 2005;33:1003-1010

22. Decrease in Ankle Injuries 116 male and female volleyball teams from Dutch 2 nd and 3 rd division Control group and intervention group did balance training Significant decreased risk of ankle sprain- in individuals with previous sprains Verhagen. AJSM 2004

23. Accidental Compensation Corporation New Zealand federal program that covers resident or visitor to New Zealand http://www.acc.co.nz/i ndex.htm SportSmart programme

24. 1. Screening Assessing health and fitness before playing identifies injury risk

25. 2. Warm-up, Cool Down and Stretch The right preparation for mind and body makes for a better performance. Cooling down helps the body to recover and is a good time for flexibility

26. 3. Physical Conditioning Staying in condition means playing to your maximum potential

27. 4. Technique Know how to play safely with good technique

28. 5. Fair Play Good sport is about positive attitude- playing fair and enjoying the game

29. 6. Protective Equipment Protect yourself against injury by using the right equipment

30. 7. Hydration and Nutrition Eating the right food and drinking adequate fluid helps maintain health and sports performance

31. 8. Injury Reporting Gathering information about injuries and monitoring how and when they occur help in injury prevention- and improve the game for everyone

32. 9. Environment It is not only the weather that counts- safe surroundings means safer play

33. 10. Injury Management Getting the right treatment sooner means less pain and a faster recovery

34. Thank You