Injuries CAN Be Prevented

Here's how to improve players' level of fitness and make a difference

By Donald T Kirkendall, Ph. D.

Preventing injuries, especially non-contact injuries, is relatively simple. The best way to prevent injury simply is to improve the level of fitness of each player. So do you just work the players harder at practice? There is more to it than that. Each player needs to improve his/her endurance, speed, flexibility, agility, strength and change their concept of what constitutes warm-up.

When I first started working in sports medicine in earnest back in the early 1980's, I heard the team doctor for the Cleveland Browns say that the biggest impact on his job was the improvement in players' fitness in the NFL. The number of non-contact injuries fell dramatically. The fitness coaches that the NFL teams had hired paid dividends. We now see that major college and professional teams never really are "detrained."

I'm not convinced that such a philosophy has permeated the soccer community. In many cases, clubs rationalize that they play all year (a topic for the future), so their players maintain their fitness. I would disagree.

What injuries are we trying to prevent? By far, the most common injury in soccer is a contusion. Muscle strains (pulled muscles) are mostly in the quads, hamstrings and groin. The most common joint injury is an ankle sprain, followed by the various knee injuries. The last group of injuries is to the head.

How would improved fitness reduce these injuries? First, remember that games are far more dangerous than training. Fatigue is a factor in nearly all injuries, as nearly one-fourth of all injuries in soccer occur in the last 10 to 15 minutes of a match. Contusions can come from a variety of reasons, such as fatigue late in the game resulting in reduced quickness and agility. Strains are a combination of muscle stretch during a forceful contraction like reaching for a tackle, shooting or during a sprint. Ankle sprains can stem from a poor reaction to an uneven surface, meaning the neuromuscular system didn't react properly. Knee ligament sprains can come from poor movement mechanics. Training can reduce all of these injuries.

This is not just for the pros. Probably the best project was in Cincinnati, when a number of local high school girls teams participated in a summer preseason training program (Heidt RS, Avoidance of soccer injuries with preseason conditioning. Am J Sports Med 28:659-662, 2000). About half the players participated and the other half were on their own as usual. The resulting injury rate was dramatically lower across the board - every category of injury was reduced in the trained group. Similar results have been reported in Australia, Norway and California.

It's pretty simple. Players need to come to training camp in some degree of shape and they need direction. Players should be doing a mixture of endurance running, intervals, agility, skill work and maintaining their flexibility and strength. They need not come in match fit, as training camp will be at a higher intensity as they are moved toward the season. The Cincinnati project incorporated a variety of components on fitness and didn't just focus on endurance.

Another reason to enter the season fit is that the scholastic and collegiate schedule is so dense with matches that, if you are lucky, you might have one day a week to devote to fitness. Is it any wonder why some teams' condition declines as the season progresses?

Once the season starts, there are activities to do in order to keep your player focused on injury prevention. These aren't exhaustive and should be a part of the preparation of every training session. Only about 15 minutes is needed to include these types of exercises in your program.

The research arm of FIFA is called F- MARC (FIFA Medical Assessment and Research Centre) and is based in Zurich. In 2003, the F-MARC people got together to prepare a manual on sports medicine for soccer. This manual is packed with soccer-specific information on fitness, injuries and prevention. The centerpiece of the manual is the FMARC 11, a set of exercises that should be done as a part of regular training that likely will be effective at preventing some of soccer's more common noncontact injuries. (Remember, no program will prevent injuries from that defender charging in full speed with spikes up.)

In October 2004, FIFA held a news conference to launch the manual, the FMARC 11 and a Swiss injury prevention program for youth soccer as the first wide application of the training and injury prevention principles. New Zealand is the next place to start this on a systematic basis.

The F-MARC directors want this program publicized to the soccer community. Posters and DVDs are in production. After a general warm-up that breaks a sweat, you can run through these exercises as a group in about 15 minutes. It may take longer until you and your players learn the routine. There is no guarantee any program will make a team injury-free, but there is good information that programs like these are very effective. Following is an outline of the program (sorry, this is so new that I can't get copyright permission for photos just yet):

No. 1: The bench

• Focus: Strengthening the core muscles for core stability
• Starting position: Lie on the stomach. Support the upper body on the forearms with the feet perpendicular to the ground (like a pushup).
• Action: Lift the stomach, hips, and knees so that the body forms a straight line from the shoulders to the heels, parallel to the ground. The elbows should be directly under the shoulders. Tighten the abdominal muscles and buttocks. Lift the right leg a few inches from the ground and hold this position for 15 seconds. Return to the starting position and repeat with the left leg. Perform 1-2 times with each leg. As fitness improves, do more, longer reps.
• Important: Do not move the hips upward or let the stomach drop. Keep a straight line.

No. 2: Sideways bench

• Focus: Strengthening the core muscles for core stability
• Starting position: Lie on one side. Support the upper body with one arm so that the elbow is vertically under the shoulder, the forearm on the ground. Bend the bottom knee 90 degrees. When viewed from above, the shoulders, elbow, hips and both knees form a straight line.
• Action: Lift the top leg and hips until the shoulder, hip and top leg are in a straight line parallel to the ground. Hold for 15 seconds. Return to the starting position, then do the other side. Perform twice on each side. As fitness improves, do more, longer reps.
• Important: Do not drop the hips. Do not tilt the upper shoulder or hips forward. Keep the straight line.

No. 3: Hamstrings

• Focus: Strengthening the hamstring muscles
• Starting position: Kneel down with the knees shoulder-width apart, keep the body straight. Cross the arms in front of the body. A partner pins the ankles to the ground.
• Action: Slowly lean forward keeping the body in a straight line from the thighs to the head. Hold this alignment as straight and as long as possible. When the hamstrings can't hold the position, use the hands to control the fall. Perform five times. As fitness improves, do more reps.
• Important: Do not bend the hips. Perform the exercise slowly.

No. 4: Cross-country skiing

• Focus: Strengthening the leg muscles
• Starting position: Stand on the right leg and let the other leg hang relaxed. Bend the hip and knee slightly so that the upper body leans forward. When viewed from the front, the hip, knee and foot of the supporting leg should be in a straight line.
• Action: Flex and extend the knee of the supporting leg and swing the arms in opposite directions in the same rhythm. Flex the knee as much as possible, but keep the weight balanced on the entire foot. Never lock the knee. Keep the pelvis and upper body stable and facing forward. Perform 15 times on the right leg, then 15 times on the left leg. As fitness improves, do more reps.
• Important: Keep the pelvis horizontal and do not let it tilt to one side. Control the knee so it doesn't buckle inward. Watch your players and correct mistakes in form.

No. 5: Chest passing in a single leg stance

• Focus: Improvement of coordination and balance; strengthening of the leg muscles.
• Starting position: Two players face each other about 10 feet apart, both standing on their right leg. Knees and hips should be slightly bent. Keep the weight on the ball of the foot with the heel slightly off the ground. When viewed from the front, the hip, knee and foot should be in a straight line.
• Action: Toss a ball back and forth. Standing on the right leg means tossing the ball with the left hand and vice versa. Catch the ball with both hands and toss back with one hand. The quicker the exchange of the ball, the more effective the exercise. Perform this 10 times on the right leg, then 10 times on the left leg. As fitness improves, do more reps.
• Important: Always keep the knee slightly bent. Do not let the leg buckle inward. Watch your players and correct mistakes in form.

No. 6: Forward bend in a single leg stance

• Focus: Improvement in coordination and balance; strengthening of the leg muscles.
• Starting position: Same as No. 5.
• Action: Same as No. 5. After catching the ball, bend forward and touch the ball to the ground before tossing the ball back to the partner. Perform 10 times for the right leg, then 10 times for the left leg. As fitness improves, do more reps.
• Important: Do not put weight on the ball when touched to the ground. When viewed from the front, the hip, knee, and foot of the supporting leg should be in a straight line. Keep the weight on the ball of the supporting foot. Do not let the knee buckle inward. Watch your players and correct mistakes in form.

No. 7: Figure 8's in a single leg stance

• Focus: Improvement in coordination and balance; strengthening the leg muscles.
• Starting position: Same as exercise 5.
• Action: Before tossing the ball back, swing the ball in a figure 8 around the support and free leg. Lean forward when passing the ball around the support leg and erect when passing the ball around the free leg. Perform 10 times while standing on the right leg and 10 on the left leg. As fitness improves, do more reps.
• Important: When viewed from the front the hip, knee and foot of the support leg should be in a straight line. Always keep the knee slightly bent and do not let the knee buckle inwards. Watch your players and correct mistakes in form.

No. 8: Jumps over a line

• Focus: Improvement of jumping power and technique
• Starting position: Stand on both feet hip width apart, about six to eight feet to the side of a line. Bend the knees and hips slightly so the upper body leans forward a little. From the front, the hip, knee and foot of each leg are in a straight line. Arms are slightly bent and close to the body.
• Action: Jump with both feet, sideways over the line and back as quickly as possible. Land softly on the balls of the feet with slightly bent knees. Jump 10 times side to side, then 10 Limes front to back over the line. As fitness improves, do more reps.
• Important: Landings should be softand quiet. Take-offs should be quick. Quickness upon take-off and soft landings is more important than jump height. Do not let the knees buckle inward. Watch this one closely for mistakes in form and insist on correct form. (Note: some coaches might have learned this at a coaching school by jumping over a ball, but I have heard of players landing on the ball and snapping a fibula).

No. 9: Zig-Zag shuffle

• Focus: Improvement in coordination, agility, jumping skill.
• Starting position: Set up six cones in a zig-zag course with about 20 yards between each cone. Players start with a shoulder facing the first cone, with the hips and knees bent and the upper body leaning substantially forward.
• Action: The player shuffles sideways to the first cone, then points the other shoulder at the next cone and shuffles to the next cone throughout the course. Take off and land on the balls of the feet. Do the course twice. As fitness improves, do more reps on a longer course (I've seen people modify this by adding carioca reps).
• Important: Keep the upper body leaning forward with a straight back. A low center of gravity is important. Land softly and quietly. Do not let the knees buckle inwards. Watch your players closely and correct mistakes in form. Reduce waiting time by setting up multiple courses.

No. 10: Bounding

• Focus: Improvement of coordination, jumping power and technique.
• Starting position: Stand on the takeoff leg with the upper body upright. The arm on the same side of the body is forward of the body. When viewed from the front, the hip, knee and support foot should be in a straight line.
• Action: Spring as high as possible off the supporting leg. Bring the knee of the free leg up as high as possible and the opposite arm bent in front of the body when bounding. Land softly and quietly on the ball of the foot with a slightly bent knee. Cover 30 yards twice. As fitness improves, do more, longer reps.
• Important: Do not let the knee buckle inward during takeoff or landing. Watch the players and correct mistakes in form

No. 11: Fair play

• Important: A substantial number of soccer injuries are caused by foul play, so the observance of the Laws of the Game and Fair Play are essential for the prevention of football injuries. PLAY FAIR.

There is a common thread among a number of these exercises. Keep the knees and hips bent to get a lower center of gravity (the old "ready position"). Stiff, erect landings lead to knee injuries, so land softly and quietly. Do your players sound like a herd of elephants when they run? Run and land softly and quietly. Players who do this are absorbing their weight and minimizing their risk of injury. Not only does it make sense, it works

Editor's note: The people of F-MARC who contributed to the development of the manual and the F-MARC 11 include Jiri Dvorak, FMARC Chairman; Astrid Junge, Colin Fuller, Toni GrafBaumann, Werner Helsen, Barbara Marquardt, Roald Bahr Lars Petersen, Bert Mandelbaum, James Sekajugo and Don Kirhendall. It is a product of FIFA Development, headed by Mary Harvey.

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