Overuse Injuries

I will point out some of the more common soccer overuse injuries I have seen or are aware of. It is not the purpose here to give details on how to manage these injuries, but to give you an idea of how they occur, how to identify them, what they involve, and in very general terms what you, as a coach, should do.

Overuse Injuries: These can also be referred to as repetitive use injuries or cumulative micro-trauma injuries. In simple terms, these are injuries that occur when the body is subjected to repeated “low stress” trauma, much like thousands of foot-strikes hitting the ground with long distance runners. Over time with these types of stresses, connective tissues (ligaments, muscles, bones) in the body begin to break down. An assembly line worker who performs a single task (turning a screwdriver for example) time after time, day after day, month after month, will eventually have upper extremity problems (tendinitis, muscle or nerve pain, etc) as a result of the repeated “micro-trauma”. When scanners first came into existence in grocery stores, clerks developed shoulder and arm problems from the repeated arm movements. Now clerks are rotated to different jobs, and some stores have right and left sided work centers so shift between left and right arm usage. “Little League Elbow” is another example of overuse in young pitchers. There are now standards for numbers of pitches permitted depending on age.

Training of youths in sports has reached near “adult levels” in terms of frequency, intensity and overall workload. This comes at a time when young bones, muscles, tendons and ligaments are still growing and developing and have not fully matured. Another reason for development of overuse injuries is the trend for players to play one sport or one activity for most of the year. This puts stress on specific body parts utilized most by that sport. When possible, it is best to take breaks from one activity and substitute another that uses different body parts. Youths who play several sports (running, swimming, cycling) use different muscles in different manners for each, resulting in less “trauma” to any specific body part and are “overall” more completely conditioning than a single sport player.

Overuse injuries can occur in soccer as well. With soccer, overuse injuries are usually the result of “too much, too soon”. The body is good at adapting to physical stresses when applied in small amounts over time. When the stresses applied build faster than the body can adapt, overuse injuries result. Some examples are listed below. I will only make brief references to some of the more common problems, it is not the purpose of this website to go into great detail. Additional information, more detailed in nature is available online. Try some of the sources I have listed on the right sidebar of this website.

Osgood-Schlatter’s Disease (knee): Sounds terrible, and while it does hurt quite a bit, it is not serious in most cases. During my year’s as a soccer coach, I had several players who developed this problem, mostly in the ages of 10-15. This problem is a result of excessive pull of the patellar tendon (connects patella or knee cap to the Tibia or lower leg bone) associated with running and jumping.

See photo below indicating the location of pain.

Before the growth plates are fully closed, the point of attachment for the tendon is bone and cartilage. Running and jumping repeatedly creates excessive pulling at this point of attachment and inflammation and even mild separation of the bone can occur. The bony prominence on the top of the Tibia where the patellar tendon attaches (bump below the kneecap-see illustration above) will be very tender to the touch, and may look a bit larger than on the opposite side. Contributing factors may be tight hamstrings, weakness, abnormal foot mechanics. The obvious solution for this is rest, ice, stretching, and when symptoms are gone, very gradual return to running, avoiding hills, and as little jumping as possible. Symptoms that don’t go away with rest, or keep coming back require referral to a physician. On rare occasions, extended rest from activity for several months may be necessary. Once the cartilage is gone and the bone is fully mature, the problem will be gone.

Achilles Tendinitis: This can occur in any one of several tendons within the foot and ankle complex. Most commonly it is the Achilles tendon in the back of the foot and ankle (shown at left). It can also involve the tendons at the side of the ankle (peroneals) or on top of the ankle (tibialis anterior). Some contributing factors might include, tight calf muscles, weakness, abnormal foot and ankle mechanics, improper footwear, lacing shoes too tight, running on uneven surfaces or hills. Over-training can be a primary cause. Again, rest, ice, correction of mechanical problems, and gradual return to activity is the best remedy. Occassionally wearing a hell lift or having inserts prescribed for shoes can help. Symptoms that don’t get better in a couple of weeks needs to be evaluated by a physician.

Heel Pain: The Achilles tendon (mentioned above) attaches to the back of the heel bone (Calcaneous). See photo to right: It is part bone and part growth plate until age 16-18 yrs approx. The strong pull of the calf muscle, tightness in the calf, and repeated running and jumping can produce excessive pull on the heel where the tendon attaches and cause something called “Sever’s Disease”. Basically it is inflammation at the back of the heel. The bone is very tender and it is painful to run and jump. Rest, ice, heel lifts and stretching are the answer. Pain that doesn’t resolve in a couple of weeks may require a visit to the family physician.

Shin Splints: This is a “catch all” term for pain in the lower leg muscles. The muscles in the lower leg are divided into “compartments”, with each compartment covered with a membrane much like a hot dog with meat in the middle covered with a thin skin. When overused, the muscles in these compartments become inflamed, swell, limiting blood flow and causing pain. Most commonly pain develops in the front (anterior compartment-left photo) or inside of the leg (posterior compartment-photo below). Soreness and tenderness to pressure will result along the outside edge of the shin bone (Tibia) or the inside between the Tibia and calf muscles. Typically, pain occurs after a sudden increase in the amount of running, or changes in running surfaces (going from soft to hard ground, or flat to hills). These would be considering over-training. Other contributing factors could include: Shoes without proper support (most soccer shoes have none), poor foot mechanics (very low or very high arches), lack of flexibility or strength imbalances. The solution is to address the cause. A reduction in the amount of running and jumping, avoiding hard surfaces (alternating hard and easy days, fewer practice sessions), correction of foot mechanics (inserts), stretching, and liberal use of ice after sessions will all help. If you have access to an athletic trainer, sometimes they will tape the shin for support, and this can provide some relief of symptoms during practice and games. Note: Shin splints can be a precursor to stress fractures explained below. As the muscles become sore, fatigue, and fail to function properly, the bones begin to bear the load of over-use.

Stress Fractures: The factors that cause this in the lower leg are similar to shin splints. A telltale sign is point tenderness directly on a spot on the Tibia (if that is the bone involved). It can also involved the bones in the foot. X-Rays and bone scans are the only valid method to make the diagnosis. Leg or foot pain that doesn’t resolve with a few days rest needs to be assessed by an MD to rule out stress fractures. Teenagers are particularly susceptible to this problem. Once diagnosed, extended rest (several weeks) is the only remedy. Many coaches like to start their season with some long runs, having their players wear sneakers to practice and taking 1-2 mile runs. Sometimes this is done on the roads. After several weeks off from sports, players legs are not accustomed to this and the “too much, too soon” rule comes into play. Coaches are encouraged to build gradually and avoid hard surfaces when possible. New high school tracks have soft, specially designed surfaces that would be less stressful on de-conditioned legs.

Other Overuse Injuries: These can virtually occur anywhere in the body. The ones listed above are the most common, but can also develop in the hip and thigh area. Generally speaking, they all occur for similar reasons and the solution is the same for most all of them. See below a few of my guidelines for keeping overuse type injuries to a minimum and how to manage them when they occur.

Prevention of Overuse injuries:

• Build the duration, intensity and frequency of practice gradually.
• Modify drills to shift emphasis on different body parts.
• Don’t neglect flexibility and strength training.
• Catch problems early, a the first sign of pain a few days rest may be all that is required.
• Encourage players to use ice after sessions on sore body parts.
• Be flexible with practice routines. Give alternate drills to do to rest sore body parts.
• Avoid hard surfaces when possible.
• Have parents address “mechanical” issues. If players have flat feet, high arches, bow legs, etc, their physician can make recommendations to see a physical therapist, podiatrist, etc.

When they occur:

• Use ice when and where appropriate after every session.
• Rest the body part involved. This could mean absence from practice or alternate drills.
• Emphasize pain-free stretching of the area.
• Address mechanical issues, ie: inserts for shoes. Done by their medical professional.
• When symptom free, return players to activity VERY GRADUALLY.
• If they do not improve with rest in a couple of weeks, refer to their family physician.

In Summary: Overuse injuries are simply what it says: OVERUSE. Building training sessions gradually, alternating hard and easy days, starting with 2 or 3 sessions weekly (practice & games) and building from there, taking an every other day approach to conditioning, using cautions with training surfaces (level, soft and stable are good), and identifying injuries in the early stages are all very important if a player is to avoid the “overuse” injury bug and keep them on the pitch and performing to their maximum. An added note; It’s important that players follow the guidelines when not training for soccer. A coach can do all the right things, but if a player is doing things on their own time that contribute to overuse injuries, they will not be successful. A careful coach can modify a soccer training session, but if the player goes to school and runs 5 miles at cross country practice, it is all wasted. Sometimes a coach must communicate with parents who, in-turn can speak with school officials and make adjustments there as well. Remember, it’s the “total workload” that a player does through that will affect their injury rate and recovery, not just what they do at soccer practice.

For more information go to the following links:

Sportsmed.org

Overuse and Over-training