CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Soccer Injuries in Childrenand AdolescentsAndrew Watson, MD, MS, FAAP,a Jeffrey M. Mjaanes, MD, FAAP,b COUNCIL ON SPORTS MEDICINE AND FITNESS

abstractParticipation in youth soccer in the United States continues to increasesteadily, with a greater percentage of preadolescent participants thanperhaps any other youth sport. Despite the wide-ranging health benefits ofparticipation in organized sports, injuries occur and represent a threat to thehealth and performance of young athletes. Youth soccer has a greaterreported injury rate than many other contact sports, and recent studiessuggest that injury rates are increasing. Large increases in the incidence ofconcussions in youth soccer have been reported, and anterior cruciateligament injuries remain a significant problem in this sport, particularlyamong female athletes. Considerable new research has identified a number ofmodifiable risk factors for lower-extremity injuries and concussion, andseveral prevention programs have been identified to reduce the risk of injury.Rule enforcement and fair play also serve an important role in reducing therisk of injury among youth soccer participants. This report provides anupdated review of the relevant literature as well as recommendations topromote the safe participation of children and adolescents in soccer.

Soccer is the most popular youth sport in the world and is 1 of the mostpopular team sports in the United States.1 It is estimated that 3.9 millionchildren and adolescents participate in soccer annually,2 and from 1990 to2014, the number of youth officially registered with US youth soccerprograms increased by almost 90%.3 Despite the wide-ranging healthbenefits of participation in organized sports, injuries occur and representa threat to both athlete health and performance.4 Unfortunately, recentstudies suggest that injury rates in youth soccer may be increasing. Sports-related injuries represent a significant and increasing economic burden tothe health care system, and the prevention of sports-related injuries inchildren has far-reaching health and economic benefits to the patient, thefamily, and the health care system as a whole. Given the number ofchildren and youth participating in youth soccer, reducing the risk ofinjury among such a large group of participants has the potential to reduceattrition rates, promote lifelong participation in sport, and facilitate the

aDepartment of Orthopedics and Rehabilitation, School of Medicineand Public Health, University of Wisconsin–Madison, Madison,Wisconsin; and bDepartment of Orthopedic Surgery, Feinberg School ofMedicine, Northwestern University, Chicago, Illinois

Drs Watson and Mjaanes served as coauthors of the manuscript,contributed substantial input into the content and revision, andapproved the final manuscript as submitted.

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authors have filedconflict of interest statements with the American Academy ofPediatrics. Any conflicts have been resolved through a processapproved by the Board of Directors. The American Academy ofPediatrics has neither solicited nor accepted any commercialinvolvement in the development of the content of this publication.

Clinical reports from the American Academy of Pediatrics benefit fromexpertise and resources of liaisons and internal (AAP) and externalreviewers. However, clinical reports from the American Academy ofPediatrics may not reflect the views of the liaisons or theorganizations or government agencies that they represent.

The guidance in this report does not indicate an exclusive course oftreatment or serve as a standard of medical care. Variations, takinginto account individual circumstances, may be appropriate.

All clinical reports from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

DOI: https://doi.org/10.1542/peds.2019-2759

Address correspondence to Andrew Watson, MD, MS, FAAP. E-mail:watson@ortho.wisc.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2019 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have nofinancial relationships relevant to this article to disclose.

FUNDING: No external funding.

To cite: Watson A, Mjaanes JM, AAP COUNCIL ON SPORTSMEDICINE AND FITNESS. Soccer Injuries in Children andAdolescents. Pediatrics. 2019;144(5):e20192759

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improvements in public healthassociated with regular exercise. Byproviding this updated clinical report,the American Academy of Pediatrics(AAP) intends to familiarize pediatrichealth care providers with currentinformation regarding the risk ofinjury in youth sport participation,strategies for injury prevention,legislative changes aimed at reducinginjury risk in youth soccer, andimportant concepts with whichpediatricians can guide families andsport governing bodies to reduce riskand facilitate participation

INJURY INCIDENCE IN YOUTH SOCCER

Injury incidence rates in youth soccervary considerably between studiesand have been reported to beanywhere from 2.0 to 19.4 injuriesper 1000 hours of exposure.5–7 Injuryincidence has been consistentlydocumented to be much greaterduring games than during training inadolescents5,8 as well as 7- to 12-year-olds.5 In a recent systematicreview of injury incidence in malesoccer players, injury rates amongadolescent athletes was found torange from 3.7 to 11.1 injuries per1000 hours in training but 9.5 to 48.7injuries per 1000 hours duringgames.5 Injury incidence appears toincrease with age, such that injuriesto players younger than 12 yearshave been reported to be 1.0 to 1.6per 1000 hours, whereas adolescentshave demonstrated an injury rate of2.6 to 15.3 per 1000 hours.6,7,9

Incidence rates may vary dependingon the specific reporting mechanism,however, and self-reportingmechanisms may identify an evengreater proportion of injuries thanthose identified through traditionalinjury reporting mechanismsinvolving a health care provider.4,9

Despite ongoing efforts to reduce therisk of injury in youth sports, injuryrates among youth soccerparticipants may be increasing andare greater than those for a numberof other team and individual sports

(see Table 1). In a recentretrospective study of 25 years ofemergency department visits, Smithet al10 found that the annual numberof soccer-related injuries among 7- to17-year-olds per 10 000 soccerparticipants increased 111% from1990 to 2014. Although it is unclearwhether this increase is attributableto greater incidence, increasedrecognition, or both; a considerableportion of this increase wasattributed to a greater number ofconcussions, with a relatively higheroverall injury incidence among girlsand adolescent athletes. A similarstudy also revealed a significantincrease in pediatric soccer-relatedinjuries evaluated in the emergencydepartment between 2000 and 2012,with significantly greater numbers ofinjuries for male youth soccerparticipants throughout the study.11

As observed with other sports, manyyoung athletes now play soccer year-round, including indoor soccer.Indoor soccer involves essentially thesame rules as outdoor soccer but isplayed on a covered field of artificialturf with walls. Futsal is a derivativeof indoor soccer but is played ona smaller indoor court with only 5players to a side and a ball smaller indiameter. Most studies involving theepidemiology of indoor soccerinjuries originate in Europe or Asiaand involve adult professionalteams.13 Despite early evidence thatindoor soccer carried a higher risk ofinjury than outdoor soccer, a morerecent study involving adolescentsoccer players revealed no significantdifferences in overall injury rates bysex or age for indoor compared withoutdoor soccer.14

INJURY TYPES AND MECHANISMS

The majority of youth soccer injuriesare acute events resulting fromplayer-to-player contact, witha considerably greater proportion ofinjuries occurring during competitionthan practice.5,15,16 With respect tosevere injuries (time loss .21 days),

incidence remains considerablyhigher during games than practice,and girls demonstrate a greaterincidence than boys (3.3 vs 2.5 per1000 athletic exposures).17 In fact,the incidence of injuries among highschool soccer players that resulted inmedical disqualification (career- orseason-ending injuries) between2005 and 2014 was found to be 0.17and 0.10 per 1000 athletic exposuresfor girls and boys, respectively.16

Among the 11 sports evaluated, theinjury rate for soccer for boys waslower only than those for football, icehockey, and lacrosse, and for girls,only gymnastics had a greater rate ofdisqualifying injury. Although not ascommon, youth soccer players arealso at risk for overuse injuries, witha recent study identifying injury ratesof 0.15 and 0.20 injuries per 10 000athletic exposures among high schoolmale and female soccer players,respectively, with knees and lowerlegs being the most commonlocations of injury.18 Although dataare limited, a single study revealedthat tendinitis, patellofemoral pain,and Osgood-Schlatter disease werethe most common overuse injuries inyouth soccer players.19

Although rates of soccer injuriesevaluated in the emergencydepartment appear to be loweramong younger soccer athletescompared with older players,10 thetypes of injuries differ by age. Aprospective study of emergencydepartment visits for soccer-relatedinjuries between 1990 and 2003suggested that 5- to 14-year-oldathletes were more likely to sufferupper-extremity injuries than highschool athletes, and high schoolathletes were more likely to suffera concussion.20 More recently,a similar study of soccer-relatedinjuries presented to emergencydepartments between 1990 and 2014revealed lower overall injury ratesamong 7- to 11-year-olds comparedwith 12- to 17-year-olds, withyounger athletes more likely to suffer

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a fracture and less likely to suffera concussion (see Table 2).10

Nonetheless, the differences betweenthese age groups appear to berelatively small, and the types ofinjuries suffered by both groupsappear to be similar overall.

Lower Extremities

The majority of injuries among youthsoccer players involve the lowerextremities. The ankles and knees arethe most commonly injured bodyparts, whereas sprains and/or strainsand contusions are the mostcommonly reported injurytypes.5,8,9,21,22 Fractures representonly approximately 3% to 10% of allinjuries but up to 28% of soccer-related injuries seen in emergencydepartments.7,8,10,23 Younger athletestend to have a lower overall injuryincidence but typically demonstratesimilar injury locations. In a study oftime-loss injuries among 417 soccerplayers ages 5 to 17 over a 2-yearperiod, ankles and knees were themost commonly injured body parts(20.9% and 16.3% of all injuries,respectively), whereas sprains,contusions, and muscle injuries werethe most common diagnoses (20.6%,22.5%, and 20.6% of all injuries,respectively). Although overuseinjuries are less common, they appearto be more common among femaleyouth soccer players, with feet and/or ankles and lower legs being themost commonly injured areas amongboys and girls.18 Among high schoolathletes, the majority of overuseinjuries were less severe, with only7.7% resulting in time loss greaterthan 21 days.18 Although the majorityof overuse injuries involveapophysitis and tendinopathy, stressfractures are another importantconsideration for youth soccerathletes.

With respect to severe injuries,player-to-player contact is the mostcommon mechanism for injuriesresulting in significant time loss (.21days)24 as well as medical

TABLE 1 Rates of Severe Injuries, Fractures, and Season-Ending Injuries in High School Sports

Injury Type Sport Rate per1000 AEs

Severea

BoysFootball 0.69Wrestling 0.52Basketball 0.24Baseball 0.19Soccer 0.25

GirlsBasketball 0.34Soccer 0.33Volleyball 0.15Softball 0.18

FractureBoys

Football 0.44Ice hockey 0.31Lacrosse 0.26Wrestling 0.23Soccer 0.20Basketball 0.16Baseball 0.15Track and field 0.02Swimming or diving 0.00

GirlsLacrosse 0.26Basketball 0.16Softball 0.15Gymnastics 0.15Soccer 0.14Field hockey 0.14Cheerleading 0.07Volleyball 0.06Track and field 0.03Swimming or diving 0.003

Season endingBoys

Football 0.26Wrestling 0.17Lacrosse 0.16Ice hockey 0.12Soccer 0.10Basketball 0.069Baseball 0.056Cross country 0.021Track and field 0.018Volleyball 0.018Swimming or diving 0.002

GirlsSoccer 0.16Basketball 0.11Lacrosse 0.093Softball 0.068Field hockey 0.061Cross country 0.056Track and field 0.048Volleyball 0.040Cheerleading 0.033Gymnastics 0.019Swimming or diving 0.005

Adapted from Darrow et al17; Swenson et al12; and Tirabassi et al.16 AE, athletic exposure.a Severe injury is defined as any injury resulting in $21 days of time lost from sport.

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disqualification.16 The knees are themost commonly affected body part inseason-ending injuries, and player-to-player contact is the most commonmechanism for both boys and girls.16

Anterior cruciate ligament (ACL)rupture remains a significant lower-extremity injury among youth soccerplayers, with noncontact valgushyperextension during rapid changeof direction or deceleration as themost common mechanism.25,26

Female soccer players appear to be atan increased risk for ACL injurycompared with their malecounterparts, and this has beenattributed to a number of factors,including lower-limb anatomy,hormonal influences, andneuromuscular activationpatterns.25,27

Concussion

Recent data suggest that concussionrates may be increasing among youthsoccer athletes, and concussionremains more common among girlsthan boys.28–30 In a recent 9-yearstudy of high school soccer players,concussion incidence was found to be0.28 and 0.45 per 1000 athleticexposures for boys and girls,

respectively. For both sexes,concussion incidence has beenfound to be greater during gamesthan during practice, and concussionrates during both practices andgames increased significantlyduring the study period.30 Finally,a recent study of soccer-relatedinjuries among 7- to 17-year-oldchildren presenting to theemergency department revealedthat concussion incidence increasednearly 1600% between 1990 and2014.10 It is unclear, however,whether this increase in concussionrates is the result of a greaternumber of concussions sustained orof increased recognition anddiagnosis of concussions asa result of previous educationefforts.

Heading is the most common sport-specific activity during whichconcussions occur, although themajority of injuries are attributable tocontact with another player whileheading rather than contact with theball itself.30,31 Concussions area result of brain acceleration aftercontact. Theoretically, concussionincidence could be reduced if themagnitude of horizontal head

acceleration could be reduced. Inaddition to the mass and velocity ofthe player, factors that affecthorizontal acceleration include themass, size, speed, and inflationpressure of the ball. Therefore, ballsthat are overinflated orinappropriately large for the age andsize of the athletes may increase therisk of head injury in young soccerplayers.32 Data are insufficient todetermine if concussions orsubconcussive impacts (repetitiveheading or blows to the head that donot result in concussive symptoms)result in potentially detrimental long-term cognitive effects.33

Facial and Ocular Injury

Although there are limited dataregarding ocular injuries in youthsoccer, a recent 10-year studyamong soccer players identified theincidence of eye injuries to be 1.0and 0.8 per 100 000 athleticexposures for boys and girls,respectively.34 The incidence of eyeinjuries was found to be higherthan that in a number of other sportsbut lower than in wrestling,basketball, and baseball for boys andlower than in field hockey andsoftball for girls. The use ofappropriate protective eyewear cansubstantially decrease the risk ofocular injuries in athletes. A recent 5-year study has revealed that amongyouth soccer players, lacerationswere the most common facial injury,followed by contusion and fracture.The nose was the most commonsite of injury, and contact with anopposing player’s head or upperextremity was the most commonmechanism.35 Dental injuries alsooccur with a frequency similar toeye injuries (1.1 per 100 000athletic exposures), with injuriesoccurring more commonly duringcompetition (3.2 per 100 000) thanduring practice (0.3 per 100 000).36

Environmental Injuries

As an outdoor sport, soccer alsocarries a potential risk for

TABLE 2 Soccer-Related Injuries Among Children 7 to 17 Years of Age Evaluated in US EmergencyDepartments by Age Group, From 1990 to 2014

7–11 y, n (%) 12–17 y, n (%)

Body region injuredUpper extremity 222 833 (27.3) 396 813 (18.2)Ankle 99 479 (12.2) 432 344 (19.9)Head or neck 124 239 (15.2) 404 356 (18.6)Knee 75 038 (9.2) 260 526 (12.0)Foot or toe 87 483 (10.7) 204 786 (9.4)Hand or finger 113 490 (13.9) 174 373 (8.0)Upper or lower leg 46 379 (5.7) 151 743 (7.0)Trunk 42 992 (5.3) 141 842 (6.5)Other 4471 (0.5) 10 990 (0.5)Subtotal 816 404 (100.0) 2 177 773 (100.0)

DiagnosisSprain or strain 242 814 (29.8) 793 437 (36.5)Fracture 231 776 (28.4) 461 611 (21.2)Soft tissue injury 192 396 (23.6) 463 469 (21.3)Concussion or CHI 45 016 (5.5) 172 346 (7.9)Other 56 598 (6.9) 139 166 (6.4)Laceration 40 339 (4.9) 102 626 (4.7)Dislocation 6793 (0.8) 43 747 (2.0)Subtotal 815 732 (100.0) 2 176 402 (100.0)

Adapted from Smith et al.10 CHI, closed head injury.

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dehydration, exertional heat illness,and other environmental dangers.Heat illness encompasses a varietyof conditions and can range from heatcramps and heat exhaustion to life-threatening heat stroke.37 Althoughthese issues may occur at anyambient temperature, the incidenceincreases with increasingtemperature and humidity. Heatcramps are painful involuntarymuscle contractions that usuallyoccur during preseasonconditioning and are treated withstretching the muscle, rest, andrehydration. Heat exhaustion isa moderate heat illnesscharacterized by the inability tocontinue exercising because ofcardiovascular insufficiencyresulting from strenuous exercise,environmental heat stress,dehydration, and energy depletion.37

Heat exhaustion typically manifestsas a headache, nausea, profusesweating, incoordination, weakness,syncope, and mildly elevated corebody temperature. Heat stroke isa life-threatening conditioncharacterized by elevated core bodytemperature .104°F (.40°C)resulting in central nervous systemdysfunction, circulatory failure, andpotential multiorgan failure.37 Initialtreatment of heat stroke includesimmediate cooling via whole bodyimmersion, if available, andtransfer to the nearest emergencydepartment. Guidelines to minimizerisk of exertional heat illness inyouth sports are applicable tosoccer, particularly during hottermonths and the early part of theseason, when players may not besufficiently acclimatized.37

Another potential hazard for thoseengaging in outdoor activities islightning. According to the NationalOceanic and Atmospheric Association,lightning strikes an average of 400people and kills 49 of these victimsevery year in the United States.38

Although there are no specific datawith respect to youth soccer, this

remains a risk in all outdoorphysical activities, and carefulmonitoring during inclementweather can identify potentiallydangerous conditions soprevention strategies can beimplemented.

Fatalities in Soccer

Fatalities in youth soccer are rareand have historically been attributableto blunt trauma with goalposts.39,40 Aprevious study of 1.6 millionemergency department visitsattributable to soccer injuries from1990 to 2003 identified 2 fatalitiesresulting from a brain hemorrhageand a ruptured spleen caused by blunttrauma.20 The US Consumer ProductSafety Commission has reported36 previous fatalities in soccer asa result of falling goalposts since1979 and has published specificrecommendations regarding properinstallation, use, and storage ofgoalposts to reduce the risk of injury.41

Footwear and Playing Surface

Footwear type and playing surfacemay affect lower-extremity injuryrates. Outdoor soccer shoes arecleated and have either bladedstuds or a combination of bladed andconical studs. Generally, bladedstuds afford greater traction andspeed; however, they may beassociated with increased rates ofinjury. In a systematic review of 23studies investigating the relationshipbetween cleat-surface interaction andinjury rates, Silva et al42 found thatbladed studs were associated with anincreased risk of injury related tohigher pressure on the lateral footborder when compared withrounded studs. Conical studs allowfor quicker release and providea greater degree of stability becausethey offer more points of contact withthe playing surface. Although thisstabilizing feature may translate toa lower risk of injury, more in vivostudies are needed. The pattern ofstud placement on cleated shoesmay also affect injury rates. A study

on American football revealed thatshoes with longer irregular cleatsplaced at the peripheral margin of thesole and a number of smaller pointedcleats positioned interiorly wereassociated with a higher risk of ACLinjuries than flat, soccer-style cleatson which the studs on the forefootwere the same height, shape, anddiameter.43

When artificial turf debuted, anincrease in lower-extremity injurieswas noted.44 Authors of initialstudies postulated that increasedshoe-surface friction producedincreased torque at the knee andankle.42 The most recent thirdgeneration of artificial turf has longergrass-like fibers embedded ingranules of sand, rubber, and/or silicaand more closely mimics naturalgrass. Several recent studies revealno difference in injury rates duringgames played on grass or turf buthigher injury rates during training ongrass.45,46 In youth soccerspecifically, a 2016 study revealedthat players who suffered a lower-extremity injury were 2.83-fold morelikely to have played on a grasssurface and were 2.40-fold morelikely to have worn cleats on grass inpractice (versus cleats on artificialturf) compared with players whowere uninjured. These researchersalso found that training on grasswas associated with a 2.8-foldincreased risk of lower-extremityinjury, but game injuries did notvary significantly when comparingartificial turf with grass.46 Thisfinding mirrors a similar study inadults that revealed no significantdifferences in the incidence of lower-extremity injuries on artificial turfor grass for male and female elitesoccer players in games.45

In the last few years, media reportshave surfaced suggesting a possiblerelationship between playing onsynthetic turf and thedevelopment of certain childhoodcancers, particularly leukemia andlymphoma.47 The basis for these

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media reports has been anecdotal,and to date, no epidemiological orlongitudinal research regardinga causative relationship betweenartificial turf and neoplasia hasbeen published.48

INJURY RISK FACTORS

Considerable recent research hasundertaken the goal of identifyingmodifiable risk factors for injury inyouth soccer, specifically related tolower-limb injuries and concussions.A number of neuromuscularimbalances have been suggested asrisk factors for injury, includingquadriceps dominance, legdominance, dynamic instability, andneuromuscular activation patterns.49

In previous research of biomechanicalrisk factors for overuse injuries inyouth soccer players, increasedquadriceps, hamstring, and hip flexorstrength were found to be protective,but increased knee valgus was foundto increase risk.19 In a singleprospective study of 11- to 15-year-old female soccer players, lownormalized knee separation duringdrop-jump testing was found to bea significant predictor of subsequentlower-limb injury.50 All of these riskfactors may be exacerbated by fatiguebecause injury risk appears to begreater during the later portions ofpractices and games51,52 as well asamong players with decreased levelsof aerobic fitness.53 In addition,previous lower-extremity injury hasbeen consistently identified as animportant risk factor that may reducestrength and alter neuromuscularrecruitment patterns.49,54,55 Althoughthis has not been studied in youthsoccer specifically, history of previousconcussion may also increase the riskof subsequent lower-limb injuryamong collegiate athletes andrepresents an important area offuture investigation.56,57

Sport participation history andtraining loads may also influence therisk of injury in youth athletes,58–60

but further information is needed toguide recommendations for soccerplayers specifically. Injury risk doesseem to increase with age, but therelationship with competition levelis unclear.61–64 A single study ofyouth soccer players revealed thatchildren in higher skill-level leagueshad reduced injuries per 1000 hourscompared with age-matchedcounterparts, although players ata higher competition level hada much higher participation volume,leading to a similar number ofabsolute injuries per year.65 Earlysport specialization has beenshown to be associated with anincreased risk of overuse injuryacross a number of youthsports.59,66–68 There are few dataregarding sport specialization andinjury risk specifically among soccerplayers, with a single recent studyof elite male adolescent soccerathletes revealing that specializationwas associated with a decreasedrisk of previous injury overall andwas not related to previous overuseinjury.69 Inadequate sleep andfatigue have been shown to be riskfactors for injury in youthathletes,60,70 although this has notbeen specifically studied in soccer.Finally, overtraining is considered animportant risk factor for injury ina number of sports, and acuteincreases in training load have beenshown to be an independent riskfactor for injury in youth soccerplayers, perhaps as a result ofimpairments in sleep and subjectivewell-being, which serve as earlyindicators of overtraining.58,71,72

An often overlooked risk factor forinjury is illegal play.73 Collins et al73

analyzed data regarding rates ofinjury attributable to activity thatwas deemed to be a violation of therules of the game in high schoolathletes involved in various sports.Soccer had the highest rates of injuryrelated to illegal activity, anda greater proportion of injuriesrelated to illegal activity involved the

head and neck, including concussion,compared with injuries from legalactivities.73

INJURY PREVENTION

Injury prevention involves theidentification of risk factors andsubsequent modification of thosefactors to decrease the likelihood ofinjury. Risk factors can be proper tothe athlete, also called intrinsic factors(such as anatomy or emotional well-being), or can originate outside theathlete, also called extrinsic factors(such as environmental conditions orplaying surface).74 Injury preventioncan be classified as primary orsecondary. With primary prevention,the aim is to prevent injuriesbefore they occur, whereas the goal forsecondary intervention is to reducethe impact of an injury once it hasoccurred.74 Most of thestrategies discussed in this report willbe focused on the primaryprevention of injuries in youthsoccer through modification of bothintrinsic and extrinsic modifiablerisk factors.

Preparticipation PhysicalExamination

The preparticipation evaluation(PPE) is a critical opportunity forprimary prevention and takes placebefore the athlete even touches thesoccer field. Although few concretedata exist to validate its use asa screening tool, a uniformly appliedPPE is generally believed to be theoptimal opportunity to detect anymedical conditions that may bepotentially life-threatening ordisabling or that may predispose theathlete to injury.75 The PPEmonograph is a collaborative effortamong several national medicalorganizations, including the AAP,and serves as a useful tool forpediatricians regarding bestpractices for performing theexamination.76

For soccer players, noting anyprevious musculoskeletal injuries,

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especially lower-extremity injuriessuch as ankle sprains, knee injuries,or groin strains, as well asa detailed history of previousconcussions or head injuries allowsfor rehabilitation if deficits areidentified. Given that cardiacetiologies account for 56% ofnontraumatic causes of suddendeath in collegiate athletes,77 notingthe presence of any cardiac-relatedsymptoms as well as a detailedfamily history of any cardiacconditions, especially hypertrophiccardiomyopathy, allows for furtherworkup. As part of a completephysical examination for sport,critical areas of focus includeassessment of the cardiovascularsystem, a baseline ocularexamination, and a thoroughmusculoskeletal examinationwith special attention to the weight-bearing joints of the lowerextremities.75

Neuromuscular and BiomechanicalTraining

As previously mentioned, ACLinjuries represent a source ofsignificant morbidity for youthsoccer players, especially girls. Thereasons for the relatively highprevalence of ACL injuries in girlsare likely multifactorial.25 Mostnoncontact ACL injuries occurwhen landing from a jump,stopping abruptly, or quicklychanging direction duringdeceleration. Compared with boys,girls tend to have a higher degreeof internal rotation at the hip andexternal rotation of the tibia whendecelerating or landing. Girls alsohave a higher tendency to land withinsufficient knee and hip flexion.78

Additionally, girls tend to havea greater degree of quadricepsactivation and differences in musclerecruitment, timing, and strength,which appear to increase the riskfor ACL injury. Given that thesebiomechanical factors representa potentially modifiable risk factorfor ACL injuries, authors of multiple

studies have investigated theeffectiveness of teaching properlanding and decelerationtechniques, muscle strengtheningand recruitment, neuromuscularwarm-up, proprioception, andplyometrics.79–81 Mandelbaum et al79

studied the effectiveness of sucha program and demonstrated a 74%to 88% reduction in ACL injury.In 2011, LaBella et al81 investigatedthe effects of a neuromuscular warm-up program in female athletes inChicago public high schools andshowed a 56% reduction innoncontact lower-extremity injuriesand a lower ACL injury rate in theintervention group. Generalrecommendations for strengtheningprograms include an emphasis ongluteal and hamstring strength andrecruitment as well as core strengthand trunk stabilization.82

Pediatricians can access a videodemonstration of such ACL injuryprevention exercises on the AAPWeb site (https://www.aap.org/en-us/about-the-aap/aap-press-room/aap-press-room-media-center/Pages/preventingACLinjury.aspx). TheFédération Internationale deFootball Association (FIFA)developed a warm-up programcalled “FIFA 111” that consisted of10 strengthening, plyometric, andproprioceptive exercises designed todecrease the frequency and severityof injuries in soccer.83 Multiplestudies have revealed the program tobe significantly effective atdecreasing the incidence of injuryin male and female youthplayers.80,83–86

Individual Player Monitoring

Overtraining, stress, and inadequaterest may individually or jointlycontribute to risk of injuries amongathletes in soccer and other youthsports.58,87,88 As previouslymentioned, an acute increase intraining load has been shown to bean independent risk factor forinjury in youth soccer players.Spurred by advances in

development of wearabletechnology, individual playermonitoring has exploded inpopularity in the last fewyears.24,89–91 Although not asprevalent as in collegiate orprofessional teams, youth teams,especially elite club and travelteams, are beginning to employ user-friendly wearable technologies tomeasure training loads,accelerations, and decelerations aswell as heart rate. Many trainingstaffs use such technologies toadjust the design, pace, andcomponents of practice sessions inan effort to maximize performanceand reduce injuries; however, thereis limited research regarding theeffectiveness of such technology inachieving these aims.

Because fatigue and inadequatesleep may be risk factors forinjury,60,70 multiple technologiesexist for monitoring sleep, such assensor-embedded wristbands andsmart phone applications; however,there is a paucity of medicalliterature regarding theireffectiveness, particularly in youngathletes. Various studies haverevealed an inverse relationshipbetween psychological well-beingand risk of injury. Steffen et al92

discovered that in female youthsoccer players ages 14 to 16 years,the risk of injury was 70% greateramong players with a high degree ofperceived life stress. Manyprofessional and collegiateprograms are now using athlete self-report measures to gauge theirathletes’ response to training withrespect to mood, motivation,perception of well-being, and stresslevels. In addition, programs arealso training athletes in mindfulnessskills, coping mechanisms, and stress-reduction strategies in an attempt tomitigate the effects of negative self-perception and stress. Swedishinvestigators conducteda randomized study in junior elitesoccer players and found that 67%

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of the players in the interventiongroup who received mindfulness-based training remained injury freeat the end of the season, comparedwith 40% in the control group.93

Concussion

Eliminating all concussions fromsoccer is unattainable; however,implementation of preventionstrategies may reduce the numberand severity of concussive injuries.

All 50 states and the District ofColumbia have passed concussionlegislation mandating schools todevelop concussion protocols andrestrict participation after sufferinga head injury.33 Most are modeledafter Washington State’s Lystedt Law,which mandates automatic removalfrom play for any suspectedconcussion, medical clearancebefore returning to sport, andeducation for parents, athletes, andcoaches. Pediatricians and otherhealth care providers areencouraged to familiarizethemselves with the preciselanguage and requirements in thelegislation regarding concussionin their individual states.

As mentioned previously, themajority of concussions in socceroccur during the act of heading butare attributable to player-playercontact, not player-ball contact.30 Ina recent study, contact with anotherplayer was the most commonmechanism of injury in heading-related concussions among boys(68.8%) and girls (51.3%).28

Because of concerns regardingheading, the US Soccer Federationunveiled an initiative aimed atreducing concussions by banningheading for children 10 years andyounger and limiting the amountof heading in practice for childrenbetween the ages of 11 and13 years.94 More research isneeded to evaluate whether thisprogram will reduce the number ofconcussions in these age groups.Instructing young soccer players in

proper heading techniques once theathletes demonstrate bodyawareness and visual trackingskills and have developed therequisite core and cervical strengthis imperative. Followingmanufacturer recommendations forproper ball inflation and size forthe age of the players also isrecommended. Finally, adherence tofair-play practice and enforcementof rules may reduce the number offoul plays and dangerous contactsand may therefore reduce the riskof concussive injuries.30

Current evidence is insufficient tosupport the uniform use ofheadgear or mouth guards toprevent concussion.95,96 Mouthguards have been shown to preventorofacial injuries; however, evidenceis mixed regarding risk reduction insports-related concussion.95,97 Theuse of soft headgear has beenstudied more extensively in rugby,in which it has been shown toreduce superficial abrasions but notaffect the overall rate of concussion.98

In laboratory testing, by usinghead forms, soccer headgear has notbeen shown to attenuate the headimpacts during simulated soccerball heading.99 Although Delaneyet al100 concluded that headgear usein youth soccer players may reducethe risk of concussion, the nationalgoverning body for soccer in theUnited States does not permit itsmembers or affiliates to require theuse of headgear by players.101 Useof padded headgear iscontroversial because of thepaucity of rigorous medicalstudies as well as concern forpossible increased risk of injuryresulting from a false sense ofsecurity.96

Fair Play and Rule Enforcement

Foul play, or actions that violate therules of the game, has been associatedwith an increased incidence ofinjuries in various levels of manysports, including soccer. In a study

of professional soccer players, foulplay was found to be involved in 14%to 37% of all injuries.102 Petersonet al65 studied soccer injuries overa 1-year period in different agegroups and skill levels and foundthat 82% of players suffered atleast 1 injury. Forty-six percent ofthe injuries were attributable tocontact, and almost half of thesewere associated with foul play.65

With respect purely to youth soccer,Emery et al103 discovered thatdirect contact was involved in46.2% of all injuries. Limiting foulplay, penalizing dangerous behavior,and properly enforcing the rulesare generally believed to reducethe risk of injury in sport.Referees, players, and spectatorsall have a responsibility toadvocate for fair play andsportsmanship.

Protective Equipment

Shin guards are the only protectivedevices that are required by FIFA,the National Collegiate AthleticAssociation, and the US SoccerFederation.104–106 Currently, shinguards are typically made ofpolypropylene and plasticcomposites, although some alsocontain fiberglass, para-aramidsynthetic fibers, or copper. Althoughthey certainly protect against legabrasions and contusions, the role ofshin guards in reducing the risk offractures has not been fullydemonstrated to date.107,108

Nevertheless, laboratory studiesindicate that shin guardssignificantly dissipate the forces andstrain on the tibia that could causefracture.109,110 Appropriately sizedshin guards should cover most of theanterior tibia, and the NationalOperating Committee for Standardsin Athletic Equipment has establishedstandards for function.111

Dental injuries can occur in allcontact sports, and soccer is noexception. Two older studiesrevealed that dental injuries account

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for 0.2% of all high school athleticinjuries,112,113 and more recent datasuggest an overall incidence rate of0.06 and 0.11 dental injuries per10 000 athletic exposures in boys’and girls’ high school soccer,respectively.36 In all of these studies,the rate of dental injuries appearsto be lower for soccer than formany other contact sports.36,112,113

Although most studies affirm thatcustom-made mouth guards conferbetter protection than the morecommon “boil and bite” type, a vastmajority of studies reveal thatsimply by wearing mouth guards,athletes can significantly decreasethe frequency and severity oforofacial injuries in contactsports.114–116

Injuries to the eye and surroundingorbit can occur in any contact orprojectile sport. Traumatic ocularinjuries have the potential forsignificant long-term morbidity.Boys account for a significantlygreater proportion of injuries thangirls, and the peak incidence occursin mid-to-late adolescence. A recentstudy revealed that socceraccounted for almost 7% of allocular trauma.117 Approximately90% of serious eye injuries arepreventable through use ofappropriate protective eyewear.118

The AAP and the American Academyof Ophthalmology classify soccer asa moderate-risk sport and stronglyrecommend that all youngparticipants wear eye protectionthat meets the American Societyfor Testing and Materials standardF803,119 which specifies thatprotective eyewear be made ofpolycarbonate, impact-resistantplastic and be worn by all athleteswho are functionally monocular orwho have a history of major eyesurgery or trauma.119

Given that sudden cardiac arrest isthe leading cause of nonaccidentaldeath in youth and can occur withathletic activity, physicians involvedwith soccer organizations are

encouraged to advocate for basic life-support training of coaches as well asplacement of automated externaldefibrillators at practice andcompetition sites.120

Environmental Safety

Heat and lightning pose an extrinsicrisk to participants in outdoorsports. The number of heat-relatedinjuries increased 133% from 1997 to2006, and youth accounted for thelargest proportion of thoseinjuries.121 Additionally, recentevidence suggests that heat-relatedillness may be increasing withclimate change.122,123 Every year,lightning accounts for dozens ofdeaths in the United States,although data regarding theincidence among youth soccerparticipants are not available.124

Precautions and simple strategiesmay reduce the risk of injury dueto adverse environmental conditions.

Heat

Some primary prevention strategiesfor heat illness includeacclimatization, activity modification,development of an emergency actionplan, and hydration.37 The risk ofheat illness appears to be highest indeconditioned athletes at the startof the season.37 Allowing athletes 7 to14 days to acclimate their bodies toheat is essential. Several state highschool organizations have formalpolicies regarding heatacclimatization. It is recommendedthat all youth teams and institutionshave a policy regarding heat thatincorporates an emergency actionplan that addresses properlymonitoring ambient weatherconditions, ideally with a wet-bulbglobe temperature device, andmodifying training sessions incertain hot and humid conditions.37

Some activity-modification strategiesinclude limiting warm-ups,scheduling hydration and restbreaks, shortening sessions orholding them earlier or later in theday, and canceling events in case of

dangerous conditions.37 Althoughthe incidence of heat illness hasnot been directly comparedbetween artificial turf and naturalgrass surfaces, significantlyelevated surface temperatureshave been reported on in-filledturf fields,125 and this may need tobe considered for soccer playedon turf.

Ensuring proper hydration beforestarting a workout and replacingfluids lost through sweating duringand after exercise are importantconsiderations for athletes.37,126

Although fluid requirements will varybetween individuals andenvironmental conditions, fluid intakeof 300 to 750 mL/hour for 9- to 12-year-olds and 1.0 to 1.5 L/hour foradolescents is typically sufficient tooffset sweat losses and reduce therisk of dehydration during intenseexercise in hot conditions.37 Water isgenerally sufficient for hydrationduring soccer competition, althoughsports drinks that contain additionalelectrolytes and carbohydrates maybe considered during periods ofprolonged, intense activity.127 Ingeneral, caffeine and energy drinks donot play a role in proper hydrationduring exercise and are notrecommended in children andadolescents.127

Lightning

Primary prevention of lightninginjuries requires careful monitoringof weather conditions. Strategies forprevention of lightning injuries bythe Centers for Disease Controland Prevention include having venue-specific emergency action plans,suspending activities whenthunder and lightning are present(typically within 6 miles), and movingathletes and spectators to sheltersdesignated specifically forlightning.128 Activities may resume30 minutes after the last strike oflightning is seen (or at least 5 milesaway) and after the last sound ofthunder is heard.38,128,129

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Footwear, Playing Surface, and FieldConditions

Some studies in soccer athletesindicate that shoes with bladed cleatsimprove performance during changesof direction but may increase thetorque and rotational movements onthe ankle and knee joints, which maytheoretically lead to injury; however,most studies reveal no increased rateof injury when comparing cleattype.42 General recommendations forsoccer footwear include ensuring thatthe shoe fits properly, that the lacesare fastened completely, and that thecleat type is appropriate for thesurface of play. Although practicingon artificial turf may be associatedwith a decreased injury riskcompared with natural grass, injuryrates during games appear to besimilar between the 2 surfaces.45,46

Regardless of the playing field type,players as well as coaches andreferees may consider checking thecondition of the field before playingto identify potential hazards, removeany debris, fill any divots or holes,and assess for areas of poor waterdrainage. The US Consumer ProductSafety Commission recommends thatmovable soccer goals be securelyanchored to the ground and only usedon level playing fields and that no oneclimbs or hangs from a post.41

CONCLUSIONS AND GUIDANCE FORPEDIATRICIANS

1. Soccer remains the most popularyouth sport in the UnitedStates, with a relatively largeproportion of preadolescentparticipants. Although injuriesoccur in soccer, injury ratesappear lower than those for manyother contact sports and areparticularly low in soccer playersyounger than 12 years of age.Pediatric health care providerscan feel comfortable withadvocating for participation insoccer as a means of promotingphysical fitness and the wide-ranging benefits of exercise.

2. Soccer is associated with certaintypes of injuries that commonlypresent to pediatric offices, school-based health clinics, andemergency departments. Theseinjuries include lower-extremitysprains, strains, fractures, andconcussions. Familiarity with themanagement of these injuries willaid the pediatrician in the care ofthis large and growing populationof young athletes.

3. ACL tears are a significant cause ofmorbidity in young soccer players,especially girls. Neuromusculartraining programs have beenshown to reduce the risk of injuryby teaching proper landing andstopping techniques anddeveloping strength and balance.Pediatricians can access a videodemonstration of such ACL injuryprevention exercises on the AAPWeb site (https://www.aap.org/en-us/about-the-aap/aap-press-room/aap-press-room-media-center/Pages/preventingACLinjury.aspx).

4. Concussions are relatively commonin soccer. Data are insufficientregarding the long-term effects ofrepetitive heading in youth soccer.Further research is neededregarding the potential protectiveeffect of headgear or interventionprograms on reducing the risk ofconcussion. The majority ofconcussions occur as a result ofcontact with an opposing playerrather than the ball; however, anemphasis on fair play, ruleenforcement, and proper age-appropriate heading techniquesmay reduce the risk of concussionin youth soccer participants.Encouraging athletes to reportsubjective symptoms facilitatesproper diagnosis and management.

5. Other injury reduction strategiesfor soccer include completion ofa PPE before the start of theseason to identify any risk factorsfor injury, proper hydration andrest, modification of activities inhot and humid weather, use of

appropriately sized shin guardsand mouth guards, and use ofproper protective eyewear,especially for athletes who arefunctionally one-eyed.

6. Adherence to fair-play rules mayreduce injuries. Physicians whowork with soccer organizationsare encouraged to advocate forenforcement of rules andpromotion of fair play at all levelsof the game. Parents, spectators,and coaches can assist referees byhonoring and promoting the spiritof fair play with young athletes.

RECOMMENDED RESOURCES

The US Consumer Product SafetyCommission guidelines formovable goals41: www.cpsc.gov/safety-education/safety-guides/sports-fitness-and-recreation/guidelines-movable-soccer-goals

The Centers for Disease Control andPrevention lightning safety tips128:www.cdc.gov/disasters/lightning/safetytips.html

The AAP ACL injury prevention videodemonstration: https://www.aap.org/en-us/about-the-aap/aap-press-room/aap-press-room-media-center/Pages/preventingACLinjury.aspx

The AAP climatic heat stress policystatement.37: http://pediatrics.aappublications.org/content/128/3/e741

LEAD AUTHORS

Andrew Watson, MD, MS, FAAPJeffrey M. Mjaanes, MD, FAAP

COUNCIL ON SPORTS MEDICINE ANDFITNESS EXECUTIVE COMMITTEE,2017–2018

Cynthia R. LaBella, MD, FAAP, ChairpersonM. Alison Brooks, MD, FAAPGreg Canty, MD, FAAPAlex B. Diamond, DO, MPH, FAAPWilliam Hennrikus, MD, FAAPKelsey Logan, MD, MPH, FAAPKody Moffatt, MD, FAAPBlaise A. Nemeth, MD, MS, FAAPK. Brooke Pengel, MD, FAAP

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Andrew R. Peterson, MD, MSPH, FAAPPaul R. Stricker, MD, FAAP

LIAISONS

Donald W. Bagnall – National AthleticTrainers’ AssociationMark E. Halstead, MD, FAAP – AmericanMedical Society for SportsMedicine

CONSULTANTS

Nicholas M. Edwards, MD, MPH, FAAPAvery D. Faigenbaum, EdD, FACSMChris G. Koutures, MD, FAAPJ. Terry Parker, PhD, ATC

STAFF

Anjie Emanuel, MPH

ABBREVIATIONS

AAP: American Academy ofPediatrics

ACL: anterior cruciate ligamentFIFA: Fédération Internationale de

Football AssociationPPE: preparticipation evaluation

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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