By Danielle Landrum, SPT
I want to welcome my audience to my third and final official FYZICAL blog post. I would love to inform everyone that I managed to save the best article for last but that statement is entirely subjective. We have frolicked into the world of pelvic floor dysfunction in female athletes, migrated into the mystery of migraine treatment, and now we are going to sashay into the world of soccer.
I might include multiple unsolicited personal anecdotes simply because this sport holds a very special place in my heart. I have spent years immersed in the sport as a player, coach, and slightly overenthusiastic fan. Soccer is the world’s most popular sport and its prevalence in the United States continues to grow each year. The training is extensive and multifaceted in order to adequately prepare for the dynamic, unpredictable nature of the game. Training soccer athletes requires finding the perfect balance between cardiovascular endurance, skilled agility, anaerobic explosiveness, and quick decision making. Even with the most elite training and extensive preparation, many players still suffer from various musculoskeletal injuries. Even the most elite soccer athletes suffer 1.5 to 7.6 injuries every 1,000 hours of training and 12 to 35 injuries every 1,000 hours of match play.1 Depending on the circumstances, a physiotherapist may or may not be present at the time of the incident, but we will certainly be present for the weeks or even months of rehabilitation. I had the privilege of working with a few high school soccer athletes at my previous rotation which needless to say was my bread and butter. A lot of these kiddos, my former teammates, and I have experienced a fair share of musculoskeletal injuries. The most commonly affected areas are often the lower extremities consisting of contusions, acute and chronic musculotendinous strains, and ligamentous injuries to the knee and ankle.2 Based on that information it is mildly reassuring to be 3 for 3 in the soccer MSK injury department.
Injury Prevention
As movement experts, we should advocate and implement a validated injury prevention tool such as the FIFA 11+.1 FIFA 11+ combines neuromuscular activation, strengthening, and plyometrics to reduce injury risk. Data shows this program has provided more than a 40% reduction in the risk of injury.1 This is an excellent tool and resource to provide for coaches, players, parents, or other clinicians. When designing an HEP for a soccer player the FIFA 11+ structure should be integrated into an off field strengthening routine or on field warm up prior to training or competition. There are numerous variations of “warm ups” that could be completed prior to training sessions but evidence-based protocols should be the standard because their effectiveness has been proven.
The Role of Physical Therapy in Soccer
Physical therapists have the knowledge to help to prevent injuries in the soccer community. We can conduct movement screenings, identify biomechanical faults, provide feedback, and design an appropriate program. Preventing injuries is just one piece to the puzzle. Whenever an individual chooses to engage in a dynamic sporting activity, there will arguably always be the risk of physical injury. We can make the essential strides for injury prevention but if and when they do happen, rehabilitation needs to be appropriate.
Any neuromuscular or therapeutic exercise will be tailored around the location and severity of the injury. Strength training will be limited depending on healing timelines and protocols. However, a big gap in physical therapy is the appropriate transition from rehabilitation to sports performance. An athlete can squat 3 sets of 10 repetitions with a 30 pound kettlebell but that is never going to prepare them for the field. We have an excellent foundation in recovery but when an athlete needs to produce or accept forces that are significantly larger than their bodyweight it could be a recipe for disaster. I would like to highlight a few training principles that could guide an effective transition back to the field. These include an eccentric emphasis of hamstrings and adductors, unilateral training, and power training.
Training Principles for a Safe Return
An eccentric emphasis on hamstrings and adductors reduces the risk of a musculotendinous injury in these regions. By training the muscles in a lengthened state, it changes the fascicle length and produces muscular adaptations which mimic the demands soccer places on the body. Some examples of exercises would include Nordic Hamstring Curls, Swiss ball bridges with a rollout, side lunges, and Copenhagen plank variations.
A large portion of the movement patterns in soccer are unilateral such as passing, shooting, dribbling, and receiving the ball. Unilateral training is important to strengthen and prime the body for those movement patterns as well as limit the severity of muscle asymmetries. Split squat variations, single leg RDL’s, single leg squatting, and weighted step downs are some resistance exercises that would be beneficial for a soccer athlete.
Power training is crucial to transition the force production from heavy strength training into reactivity, speed, and agility. Since the average soccer training session and game setting challenges power based movements it is important not to overexert or overexhaust the system. It is important to keep the force velocity curve in mind because power sits right in between absolute strength and absolute speed. Some effective power exercises include trap bar jumps, medicine ball variations, hang cleans, or a sled push.
Plyometric activities such as countermovement jumps, depth drops, box jumps, bounding, single leg hopping variations, hurdles, or agility ladder variations can reinforce speed training. These are crucial for soccer athletes to sprint fast, jump high to head the ball, and quickly change direction. Repetition with these activities translate directly into improving ground reaction forces or the amount of force the ground puts on the body during movement. This metric directly correlates to injury risk and serves as a reliable asterisk for pre versus post power training. A broad jump can be utilized for measuring horizontal power and a vertical test can be used for vertical power. A t-test is also a useful agility tool because it involves a timed forward, backward, and lateral change in direction. These three simple, time efficient tests and measures can help track progress or effectiveness of programming. In a clinical based physical therapy setting, there can often be time or equipment limitations which is why these tests could be used more often.
Merging Rehab and Performance
The audience may have skepticism as to why dosage has not been mentioned. It is because sets, repetitions, and frequency are highly variable. I could go into quantitative details but that isn’t the most riveting content to read in a blog post. Instead I wanted to discuss soccer athletes and how the physical therapy community can better serve this population through therapeutic exercise and objective measures. There are several nuances with returning to sport such as the level of competition, position, and where an athlete is in their competitive season, but for the sake of this post we are keeping things simple.
I hope after consuming my soccer content there has been some level of enlightenment or creativity sparked for future patients. I am fully aware “playing favorites” is not considered “best practice” in the world of physical therapy. So I will end by saying that a majority of these athletes are the ideal combination between skilled movers and resilient competitors who require attention to detail and creativity from their rehab. They challenge clinicians to think critically, program intentionally, and keep longevity in mind rather than chasing symptom relief. Working with this population is an opportunity to blend science, strategy, and strength in a way that elevates both the patient and the PT.
Citations
- Longo UG, Loppini M, Cavagnino R, Maffulli N, Denaro V. Musculoskeletal problems in soccer players: current concepts. Clin Cases Miner Bone Metab. 2012;9(2):107-111.
- Tucker AM. Common soccer injuries. Diagnosis, treatment and rehabilitation. Sports Med. 1997;23(1):21-32. Doi:10.2165/00007256-199723010-00003