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CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care
Soccer Injuries in Children
and Adolescents
Andrew Watson, MD, MS, FAAP,a Jeffrey M. Mjaanes, MD, FAAP,b COUNCIL ON SPORTS MEDICINE AND FITNESS
Participation in youth soccer in the United States continues to increase abstract
steadily, with a greater percentage of preadolescent participants than
a
Department of Orthopedics and Rehabilitation, School of Medicine
perhaps any other youth sport. Despite the wide-ranging health benefits of and Public Health, University of Wisconsin–Madison, Madison,
participation in organized sports, injuries occur and represent a threat to the Wisconsin; and bDepartment of Orthopedic Surgery, Feinberg School of
health and performance of young athletes. Youth soccer has a greater Medicine, Northwestern University, Chicago, Illinois
reported injury rate than many other contact sports, and recent studies Drs Watson and Mjaanes served as coauthors of the manuscript,
contributed substantial input into the content and revision, and
suggest that injury rates are increasing. Large increases in the incidence of approved the final manuscript as submitted.
concussions in youth soccer have been reported, and anterior cruciate
This document is copyrighted and is property of the American
ligament injuries remain a significant problem in this sport, particularly Academy of Pediatrics and its Board of Directors. All authors have filed
conflict of interest statements with the American Academy of
among female athletes. Considerable new research has identified a number of Pediatrics. Any conflicts have been resolved through a process
modifiable risk factors for lower-extremity injuries and concussion, and approved by the Board of Directors. The American Academy of
Pediatrics has neither solicited nor accepted any commercial
several prevention programs have been identified to reduce the risk of injury. involvement in the development of the content of this publication.
Rule enforcement and fair play also serve an important role in reducing the Clinical reports from the American Academy of Pediatrics benefit from
risk of injury among youth soccer participants. This report provides an expertise and resources of liaisons and internal (AAP) and external
reviewers. However, clinical reports from the American Academy of
updated review of the relevant literature as well as recommendations to Pediatrics may not reflect the views of the liaisons or the
promote the safe participation of children and adolescents in soccer. organizations or government agencies that they represent.
The guidance in this report does not indicate an exclusive course of
treatment or serve as a standard of medical care. Variations, taking
into account individual circumstances, may be appropriate.
All clinical reports from the American Academy of Pediatrics
Soccer is the most popular youth sport in the world and is 1 of the most automatically expire 5 years after publication unless reaffirmed,
popular team sports in the United States.1 It is estimated that 3.9 million revised, or retired at or before that time.
children and adolescents participate in soccer annually,2 and from 1990 to DOI: https://doi.org/10.1542/peds.2019-2759
2014, the number of youth officially registered with US youth soccer Address correspondence to Andrew Watson, MD, MS, FAAP. E-mail:
programs increased by almost 90%.3 Despite the wide-ranging health watson@ortho.wisc.edu
benefits of participation in organized sports, injuries occur and represent PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
a threat to both athlete health and performance.4 Unfortunately, recent Copyright © 2019 by the American Academy of Pediatrics
studies suggest that injury rates in youth soccer may be increasing. Sports-
FINANCIAL DISCLOSURE: The authors have indicated they have no
related injuries represent a significant and increasing economic burden to financial relationships relevant to this article to disclose.
the health care system, and the prevention of sports-related injuries in
FUNDING: No external funding.
children has far-reaching health and economic benefits to the patient, the
family, and the health care system as a whole. Given the number of
children and youth participating in youth soccer, reducing the risk of To cite: Watson A, Mjaanes JM, AAP COUNCIL ON SPORTS
MEDICINE AND FITNESS. Soccer Injuries in Children and
injury among such a large group of participants has the potential to reduce
Adolescents. Pediatrics. 2019;144(5):e20192759
attrition rates, promote lifelong participation in sport, and facilitate the
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PEDIATRICS Volume 144, number 5, November 2019:e20192759 FROM THE AMERICAN ACADEMY OF PEDIATRICSimprovements in public health (see Table 1). In a recent incidence remains considerably
associated with regular exercise. By retrospective study of 25 years of higher during games than practice,
providing this updated clinical report, emergency department visits, Smith and girls demonstrate a greater
the American Academy of Pediatrics et al10 found that the annual number incidence than boys (3.3 vs 2.5 per
(AAP) intends to familiarize pediatric of soccer-related injuries among 7- to 1000 athletic exposures).17 In fact,
health care providers with current 17-year-olds per 10 000 soccer the incidence of injuries among high
information regarding the risk of participants increased 111% from school soccer players that resulted in
injury in youth sport participation, 1990 to 2014. Although it is unclear medical disqualification (career- or
strategies for injury prevention, whether this increase is attributable season-ending injuries) between
legislative changes aimed at reducing to greater incidence, increased 2005 and 2014 was found to be 0.17
injury risk in youth soccer, and recognition, or both; a considerable and 0.10 per 1000 athletic exposures
important concepts with which portion of this increase was for girls and boys, respectively.16
pediatricians can guide families and attributed to a greater number of Among the 11 sports evaluated, the
sport governing bodies to reduce risk concussions, with a relatively higher injury rate for soccer for boys was
and facilitate participation overall injury incidence among girls lower only than those for football, ice
and adolescent athletes. A similar hockey, and lacrosse, and for girls,
INJURY INCIDENCE IN YOUTH SOCCER study also revealed a significant only gymnastics had a greater rate of
increase in pediatric soccer-related disqualifying injury. Although not as
Injury incidence rates in youth soccer injuries evaluated in the emergency common, youth soccer players are
vary considerably between studies department between 2000 and 2012, also at risk for overuse injuries, with
and have been reported to be with significantly greater numbers of a recent study identifying injury rates
anywhere from 2.0 to 19.4 injuries injuries for male youth soccer of 0.15 and 0.20 injuries per 10 000
per 1000 hours of exposure.5–7 Injury participants throughout the study.11 athletic exposures among high school
incidence has been consistently
As observed with other sports, many male and female soccer players,
documented to be much greater
young athletes now play soccer year- respectively, with knees and lower
during games than during training in
round, including indoor soccer. legs being the most common
adolescents5,8 as well as 7- to 12-
Indoor soccer involves essentially the locations of injury.18 Although data
year-olds.5 In a recent systematic
same rules as outdoor soccer but is are limited, a single study revealed
review of injury incidence in male
played on a covered field of artificial that tendinitis, patellofemoral pain,
soccer players, injury rates among
turf with walls. Futsal is a derivative and Osgood-Schlatter disease were
adolescent athletes was found to
of indoor soccer but is played on the most common overuse injuries in
range from 3.7 to 11.1 injuries per
a smaller indoor court with only 5 youth soccer players.19
1000 hours in training but 9.5 to 48.7
injuries per 1000 hours during players to a side and a ball smaller in
Although rates of soccer injuries
games.5 Injury incidence appears to diameter. Most studies involving the
evaluated in the emergency
increase with age, such that injuries epidemiology of indoor soccer
department appear to be lower
to players younger than 12 years injuries originate in Europe or Asia
among younger soccer athletes
have been reported to be 1.0 to 1.6 and involve adult professional
compared with older players,10 the
per 1000 hours, whereas adolescents teams.13 Despite early evidence that
types of injuries differ by age. A
have demonstrated an injury rate of indoor soccer carried a higher risk of
prospective study of emergency
2.6 to 15.3 per 1000 hours.6,7,9 injury than outdoor soccer, a more
department visits for soccer-related
Incidence rates may vary depending recent study involving adolescent
injuries between 1990 and 2003
on the specific reporting mechanism, soccer players revealed no significant
suggested that 5- to 14-year-old
however, and self-reporting differences in overall injury rates by
athletes were more likely to suffer
mechanisms may identify an even sex or age for indoor compared with
upper-extremity injuries than high
greater proportion of injuries than outdoor soccer.14
school athletes, and high school
those identified through traditional athletes were more likely to suffer
injury reporting mechanisms INJURY TYPES AND MECHANISMS a concussion.20 More recently,
involving a health care provider.4,9 The majority of youth soccer injuries a similar study of soccer-related
Despite ongoing efforts to reduce the are acute events resulting from injuries presented to emergency
risk of injury in youth sports, injury player-to-player contact, with departments between 1990 and 2014
rates among youth soccer a considerably greater proportion of revealed lower overall injury rates
participants may be increasing and injuries occurring during competition among 7- to 11-year-olds compared
are greater than those for a number than practice.5,15,16 With respect to with 12- to 17-year-olds, with
of other team and individual sports severe injuries (time loss .21 days), younger athletes more likely to suffer
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2 FROM THE AMERICAN ACADEMY OF PEDIATRICSa fracture and less likely to suffer
TABLE 1 Rates of Severe Injuries, Fractures, and Season-Ending Injuries in High School Sports
a concussion (see Table 2).10
Injury Type Sport Rate per Nonetheless, the differences between
1000 AEs
these age groups appear to be
Severea relatively small, and the types of
Boys
injuries suffered by both groups
Football 0.69
Wrestling 0.52 appear to be similar overall.
Basketball 0.24
Baseball 0.19 Lower Extremities
Soccer 0.25
Girls The majority of injuries among youth
Basketball 0.34 soccer players involve the lower
Soccer 0.33 extremities. The ankles and knees are
Volleyball 0.15
the most commonly injured body
Softball 0.18
Fracture parts, whereas sprains and/or strains
Boys and contusions are the most
Football 0.44 commonly reported injury
Ice hockey 0.31 types.5,8,9,21,22 Fractures represent
Lacrosse 0.26
only approximately 3% to 10% of all
Wrestling 0.23
Soccer 0.20 injuries but up to 28% of soccer-
Basketball 0.16 related injuries seen in emergency
Baseball 0.15 departments.7,8,10,23 Younger athletes
Track and field 0.02 tend to have a lower overall injury
Swimming or diving 0.00
incidence but typically demonstrate
Girls
Lacrosse 0.26 similar injury locations. In a study of
Basketball 0.16 time-loss injuries among 417 soccer
Softball 0.15 players ages 5 to 17 over a 2-year
Gymnastics 0.15 period, ankles and knees were the
Soccer 0.14
most commonly injured body parts
Field hockey 0.14
Cheerleading 0.07 (20.9% and 16.3% of all injuries,
Volleyball 0.06 respectively), whereas sprains,
Track and field 0.03 contusions, and muscle injuries were
Swimming or diving 0.003 the most common diagnoses (20.6%,
Season ending
22.5%, and 20.6% of all injuries,
Boys
Football 0.26 respectively). Although overuse
Wrestling 0.17 injuries are less common, they appear
Lacrosse 0.16 to be more common among female
Ice hockey 0.12 youth soccer players, with feet and/
Soccer 0.10
or ankles and lower legs being the
Basketball 0.069
Baseball 0.056 most commonly injured areas among
Cross country 0.021 boys and girls.18 Among high school
Track and field 0.018 athletes, the majority of overuse
Volleyball 0.018 injuries were less severe, with only
Swimming or diving 0.002
7.7% resulting in time loss greater
Girls
Soccer 0.16 than 21 days.18 Although the majority
Basketball 0.11 of overuse injuries involve
Lacrosse 0.093 apophysitis and tendinopathy, stress
Softball 0.068 fractures are another important
Field hockey 0.061
consideration for youth soccer
Cross country 0.056
Track and field 0.048 athletes.
Volleyball 0.040
With respect to severe injuries,
Cheerleading 0.033
Gymnastics 0.019 player-to-player contact is the most
Swimming or diving 0.005 common mechanism for injuries
Adapted from Darrow et al17; Swenson et al12; and Tirabassi et al.16 AE, athletic exposure. resulting in significant time loss (.21
a Severe injury is defined as any injury resulting in $21 days of time lost from sport. days)24 as well as medical
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PEDIATRICS Volume 144, number 5, November 2019 3TABLE 2 Soccer-Related Injuries Among Children 7 to 17 Years of Age Evaluated in US Emergency acceleration could be reduced. In
Departments by Age Group, From 1990 to 2014 addition to the mass and velocity of
7–11 y, n (%) 12–17 y, n (%) the player, factors that affect
Body region injured horizontal acceleration include the
Upper extremity 222 833 (27.3) 396 813 (18.2) mass, size, speed, and inflation
Ankle 99 479 (12.2) 432 344 (19.9) pressure of the ball. Therefore, balls
Head or neck 124 239 (15.2) 404 356 (18.6) that are overinflated or
Knee 75 038 (9.2) 260 526 (12.0)
inappropriately large for the age and
Foot or toe 87 483 (10.7) 204 786 (9.4)
Hand or finger 113 490 (13.9) 174 373 (8.0) size of the athletes may increase the
Upper or lower leg 46 379 (5.7) 151 743 (7.0) risk of head injury in young soccer
Trunk 42 992 (5.3) 141 842 (6.5) players.32 Data are insufficient to
Other 4471 (0.5) 10 990 (0.5) determine if concussions or
Subtotal 816 404 (100.0) 2 177 773 (100.0)
subconcussive impacts (repetitive
Diagnosis
Sprain or strain 242 814 (29.8) 793 437 (36.5) heading or blows to the head that do
Fracture 231 776 (28.4) 461 611 (21.2) not result in concussive symptoms)
Soft tissue injury 192 396 (23.6) 463 469 (21.3) result in potentially detrimental long-
Concussion or CHI 45 016 (5.5) 172 346 (7.9) term cognitive effects.33
Other 56 598 (6.9) 139 166 (6.4)
Laceration 40 339 (4.9) 102 626 (4.7) Facial and Ocular Injury
Dislocation 6793 (0.8) 43 747 (2.0)
Subtotal 815 732 (100.0) 2 176 402 (100.0) Although there are limited data
10
Adapted from Smith et al. CHI, closed head injury. regarding ocular injuries in youth
soccer, a recent 10-year study
among soccer players identified the
disqualification.16 The knees are the respectively. For both sexes, incidence of eye injuries to be 1.0
most commonly affected body part in concussion incidence has been and 0.8 per 100 000 athletic
season-ending injuries, and player-to- found to be greater during games exposures for boys and girls,
player contact is the most common than during practice, and concussion respectively.34 The incidence of eye
mechanism for both boys and girls.16 rates during both practices and injuries was found to be higher
Anterior cruciate ligament (ACL) games increased significantly than that in a number of other sports
rupture remains a significant lower- during the study period.30 Finally, but lower than in wrestling,
extremity injury among youth soccer a recent study of soccer-related basketball, and baseball for boys and
players, with noncontact valgus injuries among 7- to 17-year-old lower than in field hockey and
hyperextension during rapid change children presenting to the softball for girls. The use of
of direction or deceleration as the emergency department revealed appropriate protective eyewear can
most common mechanism.25,26 that concussion incidence increased substantially decrease the risk of
Female soccer players appear to be at nearly 1600% between 1990 and ocular injuries in athletes. A recent 5-
an increased risk for ACL injury 2014.10 It is unclear, however, year study has revealed that among
compared with their male whether this increase in concussion youth soccer players, lacerations
counterparts, and this has been rates is the result of a greater were the most common facial injury,
attributed to a number of factors, number of concussions sustained or followed by contusion and fracture.
including lower-limb anatomy, of increased recognition and The nose was the most common
hormonal influences, and diagnosis of concussions as site of injury, and contact with an
neuromuscular activation a result of previous education opposing player’s head or upper
patterns.25,27 efforts. extremity was the most common
Heading is the most common sport- mechanism.35 Dental injuries also
Concussion specific activity during which occur with a frequency similar to
Recent data suggest that concussion concussions occur, although the eye injuries (1.1 per 100 000
rates may be increasing among youth majority of injuries are attributable to athletic exposures), with injuries
soccer athletes, and concussion contact with another player while occurring more commonly during
remains more common among girls heading rather than contact with the competition (3.2 per 100 000) than
than boys.28–30 In a recent 9-year ball itself.30,31 Concussions are during practice (0.3 per 100 000).36
study of high school soccer players, a result of brain acceleration after
concussion incidence was found to be contact. Theoretically, concussion Environmental Injuries
0.28 and 0.45 per 1000 athletic incidence could be reduced if the As an outdoor sport, soccer also
exposures for boys and girls, magnitude of horizontal head carries a potential risk for
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4 FROM THE AMERICAN ACADEMY OF PEDIATRICSdehydration, exertional heat illness, remains a risk in all outdoor on American football revealed that
and other environmental dangers. physical activities, and careful shoes with longer irregular cleats
Heat illness encompasses a variety monitoring during inclement placed at the peripheral margin of the
of conditions and can range from heat weather can identify potentially sole and a number of smaller pointed
cramps and heat exhaustion to life- dangerous conditions so cleats positioned interiorly were
threatening heat stroke.37 Although prevention strategies can be associated with a higher risk of ACL
these issues may occur at any implemented. injuries than flat, soccer-style cleats
ambient temperature, the incidence on which the studs on the forefoot
increases with increasing Fatalities in Soccer were the same height, shape, and
temperature and humidity. Heat Fatalities in youth soccer are rare diameter.43
cramps are painful involuntary and have historically been attributable
When artificial turf debuted, an
muscle contractions that usually to blunt trauma with goalposts.39,40 A
increase in lower-extremity injuries
occur during preseason previous study of 1.6 million
was noted.44 Authors of initial
conditioning and are treated with emergency department visits
studies postulated that increased
stretching the muscle, rest, and attributable to soccer injuries from
shoe-surface friction produced
rehydration. Heat exhaustion is 1990 to 2003 identified 2 fatalities
increased torque at the knee and
a moderate heat illness resulting from a brain hemorrhage
ankle.42 The most recent third
characterized by the inability to and a ruptured spleen caused by blunt
generation of artificial turf has longer
continue exercising because of trauma.20 The US Consumer Product
grass-like fibers embedded in
cardiovascular insufficiency Safety Commission has reported
granules of sand, rubber, and/or silica
resulting from strenuous exercise, 36 previous fatalities in soccer as
and more closely mimics natural
environmental heat stress, a result of falling goalposts since
grass. Several recent studies reveal
dehydration, and energy depletion.37 1979 and has published specific
no difference in injury rates during
Heat exhaustion typically manifests recommendations regarding proper
games played on grass or turf but
as a headache, nausea, profuse installation, use, and storage of
higher injury rates during training on
sweating, incoordination, weakness, goalposts to reduce the risk of injury.41
grass.45,46 In youth soccer
syncope, and mildly elevated core
Footwear and Playing Surface specifically, a 2016 study revealed
body temperature. Heat stroke is
that players who suffered a lower-
a life-threatening condition Footwear type and playing surface
extremity injury were 2.83-fold more
characterized by elevated core body may affect lower-extremity injury
likely to have played on a grass
temperature .104°F (.40°C) rates. Outdoor soccer shoes are
surface and were 2.40-fold more
resulting in central nervous system cleated and have either bladed
likely to have worn cleats on grass in
dysfunction, circulatory failure, and studs or a combination of bladed and
practice (versus cleats on artificial
potential multiorgan failure.37 Initial conical studs. Generally, bladed
turf) compared with players who
treatment of heat stroke includes studs afford greater traction and
were uninjured. These researchers
immediate cooling via whole body speed; however, they may be
also found that training on grass
immersion, if available, and associated with increased rates of
was associated with a 2.8-fold
transfer to the nearest emergency injury. In a systematic review of 23
increased risk of lower-extremity
department. Guidelines to minimize studies investigating the relationship
injury, but game injuries did not
risk of exertional heat illness in between cleat-surface interaction and
vary significantly when comparing
youth sports are applicable to injury rates, Silva et al42 found that
artificial turf with grass.46 This
soccer, particularly during hotter bladed studs were associated with an
finding mirrors a similar study in
months and the early part of the increased risk of injury related to
adults that revealed no significant
season, when players may not be higher pressure on the lateral foot
differences in the incidence of lower-
sufficiently acclimatized.37 border when compared with
extremity injuries on artificial turf
rounded studs. Conical studs allow
or grass for male and female elite
Another potential hazard for those for quicker release and provide
soccer players in games.45
engaging in outdoor activities is a greater degree of stability because
lightning. According to the National they offer more points of contact with In the last few years, media reports
Oceanic and Atmospheric Association, the playing surface. Although this have surfaced suggesting a possible
lightning strikes an average of 400 stabilizing feature may translate to relationship between playing on
people and kills 49 of these victims a lower risk of injury, more in vivo synthetic turf and the
every year in the United States.38 studies are needed. The pattern of development of certain childhood
Although there are no specific data stud placement on cleated shoes cancers, particularly leukemia and
with respect to youth soccer, this may also affect injury rates. A study lymphoma.47 The basis for these
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PEDIATRICS Volume 144, number 5, November 2019 5media reports has been anecdotal, but further information is needed to head and neck, including concussion,
and to date, no epidemiological or guide recommendations for soccer compared with injuries from legal
longitudinal research regarding players specifically. Injury risk does activities.73
a causative relationship between seem to increase with age, but the
artificial turf and neoplasia has relationship with competition level INJURY PREVENTION
been published.48 is unclear.61–64 A single study of
youth soccer players revealed that Injury prevention involves the
children in higher skill-level leagues identification of risk factors and
INJURY RISK FACTORS had reduced injuries per 1000 hours subsequent modification of those
compared with age-matched factors to decrease the likelihood of
Considerable recent research has injury. Risk factors can be proper to
undertaken the goal of identifying counterparts, although players at
a higher competition level had the athlete, also called intrinsic factors
modifiable risk factors for injury in (such as anatomy or emotional well-
youth soccer, specifically related to a much higher participation volume,
leading to a similar number of being), or can originate outside the
lower-limb injuries and concussions. athlete, also called extrinsic factors
A number of neuromuscular absolute injuries per year.65 Early
sport specialization has been (such as environmental conditions or
imbalances have been suggested as playing surface).74 Injury prevention
risk factors for injury, including shown to be associated with an
increased risk of overuse injury can be classified as primary or
quadriceps dominance, leg secondary. With primary prevention,
dominance, dynamic instability, and across a number of youth
sports.59,66–68 There are few data the aim is to prevent injuries
neuromuscular activation patterns.49 before they occur, whereas the goal for
In previous research of biomechanical regarding sport specialization and
injury risk specifically among soccer secondary intervention is to reduce
risk factors for overuse injuries in the impact of an injury once it has
youth soccer players, increased players, with a single recent study
of elite male adolescent soccer occurred.74 Most of the
quadriceps, hamstring, and hip flexor strategies discussed in this report will
strength were found to be protective, athletes revealing that specialization
was associated with a decreased be focused on the primary
but increased knee valgus was found prevention of injuries in youth
to increase risk.19 In a single risk of previous injury overall and
was not related to previous overuse soccer through modification of both
prospective study of 11- to 15-year- intrinsic and extrinsic modifiable
old female soccer players, low injury.69 Inadequate sleep and
fatigue have been shown to be risk risk factors.
normalized knee separation during
drop-jump testing was found to be factors for injury in youth Preparticipation Physical
a significant predictor of subsequent athletes,60,70 although this has not Examination
lower-limb injury.50 All of these risk been specifically studied in soccer.
The preparticipation evaluation
factors may be exacerbated by fatigue Finally, overtraining is considered an
(PPE) is a critical opportunity for
because injury risk appears to be important risk factor for injury in
primary prevention and takes place
greater during the later portions of a number of sports, and acute
before the athlete even touches the
practices and games51,52 as well as increases in training load have been
soccer field. Although few concrete
among players with decreased levels shown to be an independent risk
data exist to validate its use as
of aerobic fitness.53 In addition, factor for injury in youth soccer
a screening tool, a uniformly applied
previous lower-extremity injury has players, perhaps as a result of
PPE is generally believed to be the
been consistently identified as an impairments in sleep and subjective
optimal opportunity to detect any
important risk factor that may reduce well-being, which serve as early
medical conditions that may be
strength and alter neuromuscular indicators of overtraining.58,71,72
potentially life-threatening or
recruitment patterns.49,54,55 Although disabling or that may predispose the
this has not been studied in youth An often overlooked risk factor for
injury is illegal play.73 Collins et al73 athlete to injury.75 The PPE
soccer specifically, history of previous monograph is a collaborative effort
concussion may also increase the risk analyzed data regarding rates of
injury attributable to activity that among several national medical
of subsequent lower-limb injury organizations, including the AAP,
among collegiate athletes and was deemed to be a violation of the
rules of the game in high school and serves as a useful tool for
represents an important area of pediatricians regarding best
future investigation.56,57 athletes involved in various sports.
Soccer had the highest rates of injury practices for performing the
Sport participation history and related to illegal activity, and examination.76
training loads may also influence the a greater proportion of injuries For soccer players, noting any
risk of injury in youth athletes,58–60 related to illegal activity involved the previous musculoskeletal injuries,
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6 FROM THE AMERICAN ACADEMY OF PEDIATRICSespecially lower-extremity injuries studies have investigated the development of wearable
such as ankle sprains, knee injuries, effectiveness of teaching proper technology, individual player
or groin strains, as well as landing and deceleration monitoring has exploded in
a detailed history of previous techniques, muscle strengthening popularity in the last few
concussions or head injuries allows and recruitment, neuromuscular years.24,89–91 Although not as
for rehabilitation if deficits are warm-up, proprioception, and prevalent as in collegiate or
identified. Given that cardiac plyometrics.79–81 Mandelbaum et al79 professional teams, youth teams,
etiologies account for 56% of studied the effectiveness of such especially elite club and travel
nontraumatic causes of sudden a program and demonstrated a 74% teams, are beginning to employ user-
death in collegiate athletes,77 noting to 88% reduction in ACL injury. friendly wearable technologies to
the presence of any cardiac-related In 2011, LaBella et al81 investigated measure training loads,
symptoms as well as a detailed the effects of a neuromuscular warm- accelerations, and decelerations as
family history of any cardiac up program in female athletes in well as heart rate. Many training
conditions, especially hypertrophic Chicago public high schools and staffs use such technologies to
cardiomyopathy, allows for further showed a 56% reduction in adjust the design, pace, and
workup. As part of a complete noncontact lower-extremity injuries components of practice sessions in
physical examination for sport, and a lower ACL injury rate in the an effort to maximize performance
critical areas of focus include intervention group. General and reduce injuries; however, there
assessment of the cardiovascular recommendations for strengthening is limited research regarding the
system, a baseline ocular programs include an emphasis on effectiveness of such technology in
examination, and a thorough gluteal and hamstring strength and achieving these aims.
musculoskeletal examination recruitment as well as core strength
with special attention to the weight- and trunk stabilization.82 Because fatigue and inadequate
bearing joints of the lower Pediatricians can access a video sleep may be risk factors for
extremities.75 demonstration of such ACL injury injury,60,70 multiple technologies
prevention exercises on the AAP exist for monitoring sleep, such as
Neuromuscular and Biomechanical Web site (https://www.aap.org/en- sensor-embedded wristbands and
Training us/about-the-aap/aap-press-room/ smart phone applications; however,
As previously mentioned, ACL aap-press-room-media-center/Pages/ there is a paucity of medical
injuries represent a source of preventingACLinjury.aspx). The literature regarding their
significant morbidity for youth Fédération Internationale de effectiveness, particularly in young
soccer players, especially girls. The Football Association (FIFA) athletes. Various studies have
reasons for the relatively high developed a warm-up program revealed an inverse relationship
prevalence of ACL injuries in girls called “FIFA 111” that consisted of between psychological well-being
are likely multifactorial.25 Most 10 strengthening, plyometric, and and risk of injury. Steffen et al92
noncontact ACL injuries occur proprioceptive exercises designed to discovered that in female youth
when landing from a jump, decrease the frequency and severity soccer players ages 14 to 16 years,
stopping abruptly, or quickly of injuries in soccer.83 Multiple the risk of injury was 70% greater
changing direction during studies have revealed the program to among players with a high degree of
deceleration. Compared with boys, be significantly effective at perceived life stress. Many
girls tend to have a higher degree decreasing the incidence of injury professional and collegiate
of internal rotation at the hip and in male and female youth programs are now using athlete self-
external rotation of the tibia when players.80,83–86 report measures to gauge their
decelerating or landing. Girls also athletes’ response to training with
have a higher tendency to land with Individual Player Monitoring respect to mood, motivation,
insufficient knee and hip flexion.78 Overtraining, stress, and inadequate perception of well-being, and stress
Additionally, girls tend to have rest may individually or jointly levels. In addition, programs are
a greater degree of quadriceps contribute to risk of injuries among also training athletes in mindfulness
activation and differences in muscle athletes in soccer and other youth skills, coping mechanisms, and stress-
recruitment, timing, and strength, sports.58,87,88 As previously reduction strategies in an attempt to
which appear to increase the risk mentioned, an acute increase in mitigate the effects of negative self-
for ACL injury. Given that these training load has been shown to be perception and stress. Swedish
biomechanical factors represent an independent risk factor for investigators conducted
a potentially modifiable risk factor injury in youth soccer players. a randomized study in junior elite
for ACL injuries, authors of multiple Spurred by advances in soccer players and found that 67%
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PEDIATRICS Volume 144, number 5, November 2019 7of the players in the intervention proper heading techniques once the of professional soccer players, foul
group who received mindfulness- athletes demonstrate body play was found to be involved in 14%
based training remained injury free awareness and visual tracking to 37% of all injuries.102 Peterson
at the end of the season, compared skills and have developed the et al65 studied soccer injuries over
with 40% in the control group.93 requisite core and cervical strength a 1-year period in different age
is imperative. Following groups and skill levels and found
Concussion manufacturer recommendations for that 82% of players suffered at
Eliminating all concussions from proper ball inflation and size for least 1 injury. Forty-six percent of
soccer is unattainable; however, the age of the players also is the injuries were attributable to
implementation of prevention recommended. Finally, adherence to contact, and almost half of these
strategies may reduce the number fair-play practice and enforcement were associated with foul play.65
and severity of concussive injuries. of rules may reduce the number of With respect purely to youth soccer,
foul plays and dangerous contacts Emery et al103 discovered that
All 50 states and the District of
and may therefore reduce the risk direct contact was involved in
Columbia have passed concussion
of concussive injuries.30 46.2% of all injuries. Limiting foul
legislation mandating schools to
play, penalizing dangerous behavior,
develop concussion protocols and Current evidence is insufficient to
and properly enforcing the rules
restrict participation after suffering support the uniform use of
are generally believed to reduce
a head injury.33 Most are modeled headgear or mouth guards to
the risk of injury in sport.
after Washington State’s Lystedt Law, prevent concussion.95,96 Mouth
Referees, players, and spectators
which mandates automatic removal guards have been shown to prevent
all have a responsibility to
from play for any suspected orofacial injuries; however, evidence
advocate for fair play and
concussion, medical clearance is mixed regarding risk reduction in
sportsmanship.
before returning to sport, and sports-related concussion.95,97 The
education for parents, athletes, and use of soft headgear has been
Protective Equipment
coaches. Pediatricians and other studied more extensively in rugby,
health care providers are in which it has been shown to Shin guards are the only protective
encouraged to familiarize reduce superficial abrasions but not devices that are required by FIFA,
themselves with the precise affect the overall rate of concussion.98 the National Collegiate Athletic
language and requirements in the In laboratory testing, by using Association, and the US Soccer
legislation regarding concussion head forms, soccer headgear has not Federation.104–106 Currently, shin
in their individual states. been shown to attenuate the head guards are typically made of
impacts during simulated soccer polypropylene and plastic
As mentioned previously, the
ball heading.99 Although Delaney composites, although some also
majority of concussions in soccer
et al100 concluded that headgear use contain fiberglass, para-aramid
occur during the act of heading but
in youth soccer players may reduce synthetic fibers, or copper. Although
are attributable to player-player
the risk of concussion, the national they certainly protect against leg
contact, not player-ball contact.30 In
governing body for soccer in the abrasions and contusions, the role of
a recent study, contact with another
United States does not permit its shin guards in reducing the risk of
player was the most common
members or affiliates to require the fractures has not been fully
mechanism of injury in heading-
use of headgear by players.101 Use demonstrated to date.107,108
related concussions among boys
of padded headgear is Nevertheless, laboratory studies
(68.8%) and girls (51.3%).28
controversial because of the indicate that shin guards
Because of concerns regarding
paucity of rigorous medical significantly dissipate the forces and
heading, the US Soccer Federation
studies as well as concern for strain on the tibia that could cause
unveiled an initiative aimed at
possible increased risk of injury fracture.109,110 Appropriately sized
reducing concussions by banning
resulting from a false sense of shin guards should cover most of the
heading for children 10 years and
security.96 anterior tibia, and the National
younger and limiting the amount
Operating Committee for Standards
of heading in practice for children
Fair Play and Rule Enforcement in Athletic Equipment has established
between the ages of 11 and
standards for function.111
13 years.94 More research is Foul play, or actions that violate the
needed to evaluate whether this rules of the game, has been associated Dental injuries can occur in all
program will reduce the number of with an increased incidence of contact sports, and soccer is no
concussions in these age groups. injuries in various levels of many exception. Two older studies
Instructing young soccer players in sports, including soccer. In a study revealed that dental injuries account
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8 FROM THE AMERICAN ACADEMY OF PEDIATRICSfor 0.2% of all high school athletic encouraged to advocate for basic life- dangerous conditions.37 Although
injuries,112,113 and more recent data support training of coaches as well as the incidence of heat illness has
suggest an overall incidence rate of placement of automated external not been directly compared
0.06 and 0.11 dental injuries per defibrillators at practice and between artificial turf and natural
10 000 athletic exposures in boys’ competition sites.120 grass surfaces, significantly
and girls’ high school soccer, elevated surface temperatures
respectively.36 In all of these studies, Environmental Safety have been reported on in-filled
the rate of dental injuries appears Heat and lightning pose an extrinsic turf fields,125 and this may need to
to be lower for soccer than for risk to participants in outdoor be considered for soccer played
many other contact sports.36,112,113 sports. The number of heat-related on turf.
Although most studies affirm that injuries increased 133% from 1997 to
Ensuring proper hydration before
custom-made mouth guards confer 2006, and youth accounted for the
starting a workout and replacing
better protection than the more largest proportion of those
fluids lost through sweating during
common “boil and bite” type, a vast injuries.121 Additionally, recent
and after exercise are important
majority of studies reveal that evidence suggests that heat-related
considerations for athletes.37,126
simply by wearing mouth guards, illness may be increasing with
Although fluid requirements will vary
athletes can significantly decrease climate change.122,123 Every year,
between individuals and
the frequency and severity of lightning accounts for dozens of
environmental conditions, fluid intake
orofacial injuries in contact deaths in the United States,
of 300 to 750 mL/hour for 9- to 12-
sports.114–116 although data regarding the
year-olds and 1.0 to 1.5 L/hour for
incidence among youth soccer
Injuries to the eye and surrounding adolescents is typically sufficient to
participants are not available.124
orbit can occur in any contact or offset sweat losses and reduce the
Precautions and simple strategies
projectile sport. Traumatic ocular risk of dehydration during intense
may reduce the risk of injury due
injuries have the potential for exercise in hot conditions.37 Water is
to adverse environmental conditions.
significant long-term morbidity. generally sufficient for hydration
Boys account for a significantly Heat during soccer competition, although
greater proportion of injuries than sports drinks that contain additional
Some primary prevention strategies
girls, and the peak incidence occurs electrolytes and carbohydrates may
for heat illness include
in mid-to-late adolescence. A recent be considered during periods of
acclimatization, activity modification,
study revealed that soccer prolonged, intense activity.127 In
development of an emergency action
accounted for almost 7% of all general, caffeine and energy drinks do
plan, and hydration.37 The risk of
ocular trauma.117 Approximately not play a role in proper hydration
heat illness appears to be highest in
90% of serious eye injuries are during exercise and are not
deconditioned athletes at the start
preventable through use of recommended in children and
of the season.37 Allowing athletes 7 to
appropriate protective eyewear.118 adolescents.127
14 days to acclimate their bodies to
The AAP and the American Academy
heat is essential. Several state high
of Ophthalmology classify soccer as Lightning
school organizations have formal
a moderate-risk sport and strongly
policies regarding heat Primary prevention of lightning
recommend that all young
acclimatization. It is recommended injuries requires careful monitoring
participants wear eye protection
that all youth teams and institutions of weather conditions. Strategies for
that meets the American Society
have a policy regarding heat that prevention of lightning injuries by
for Testing and Materials standard
incorporates an emergency action the Centers for Disease Control
F803,119 which specifies that
plan that addresses properly and Prevention include having venue-
protective eyewear be made of
monitoring ambient weather specific emergency action plans,
polycarbonate, impact-resistant
conditions, ideally with a wet-bulb suspending activities when
plastic and be worn by all athletes
globe temperature device, and thunder and lightning are present
who are functionally monocular or
modifying training sessions in (typically within 6 miles), and moving
who have a history of major eye
certain hot and humid conditions.37 athletes and spectators to shelters
surgery or trauma.119
Some activity-modification strategies designated specifically for
Given that sudden cardiac arrest is include limiting warm-ups, lightning.128 Activities may resume
the leading cause of nonaccidental scheduling hydration and rest 30 minutes after the last strike of
death in youth and can occur with breaks, shortening sessions or lightning is seen (or at least 5 miles
athletic activity, physicians involved holding them earlier or later in the away) and after the last sound of
with soccer organizations are day, and canceling events in case of thunder is heard.38,128,129
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PEDIATRICS Volume 144, number 5, November 2019 9Footwear, Playing Surface, and Field 2. Soccer is associated with certain appropriately sized shin guards
Conditions types of injuries that commonly and mouth guards, and use of
Some studies in soccer athletes present to pediatric offices, school- proper protective eyewear,
indicate that shoes with bladed cleats based health clinics, and especially for athletes who are
improve performance during changes emergency departments. These functionally one-eyed.
of direction but may increase the injuries include lower-extremity 6. Adherence to fair-play rules may
torque and rotational movements on sprains, strains, fractures, and reduce injuries. Physicians who
the ankle and knee joints, which may concussions. Familiarity with the work with soccer organizations
theoretically lead to injury; however, management of these injuries will are encouraged to advocate for
most studies reveal no increased rate aid the pediatrician in the care of enforcement of rules and
of injury when comparing cleat this large and growing population promotion of fair play at all levels
type.42 General recommendations for of young athletes. of the game. Parents, spectators,
soccer footwear include ensuring that 3. ACL tears are a significant cause of and coaches can assist referees by
the shoe fits properly, that the laces morbidity in young soccer players, honoring and promoting the spirit
are fastened completely, and that the especially girls. Neuromuscular of fair play with young athletes.
cleat type is appropriate for the training programs have been
surface of play. Although practicing shown to reduce the risk of injury RECOMMENDED RESOURCES
on artificial turf may be associated by teaching proper landing and The US Consumer Product Safety
with a decreased injury risk stopping techniques and Commission guidelines for
compared with natural grass, injury developing strength and balance. movable goals41: www.cpsc.gov/
rates during games appear to be Pediatricians can access a video safety-education/safety-guides/
similar between the 2 surfaces.45,46 demonstration of such ACL injury sports-fitness-and-recreation/
Regardless of the playing field type, prevention exercises on the AAP guidelines-movable-soccer-goals
players as well as coaches and Web site (https://www.aap.org/en-
The Centers for Disease Control and
referees may consider checking the us/about-the-aap/aap-press-room/
Prevention lightning safety tips128:
condition of the field before playing aap-press-room-media-center/
www.cdc.gov/disasters/lightning/
to identify potential hazards, remove Pages/preventingACLinjury.aspx).
safetytips.html
any debris, fill any divots or holes, 4. Concussions are relatively common
and assess for areas of poor water The AAP ACL injury prevention video
in soccer. Data are insufficient
drainage. The US Consumer Product demonstration: https://www.aap.o
regarding the long-term effects of
Safety Commission recommends that rg/en-us/about-the-aap/aap-pre
repetitive heading in youth soccer.
movable soccer goals be securely ss-room/aap-press-room-media-ce
Further research is needed
anchored to the ground and only used nter/Pages/preventingACLinjury.a
regarding the potential protective
on level playing fields and that no one effect of headgear or intervention
spx
climbs or hangs from a post.41 programs on reducing the risk of The AAP climatic heat stress policy
concussion. The majority of statement.37: http://pediatrics.
concussions occur as a result of aappublications.org/content/128/
CONCLUSIONS AND GUIDANCE FOR
PEDIATRICIANS contact with an opposing player 3/e741
1. Soccer remains the most popular rather than the ball; however, an
youth sport in the United emphasis on fair play, rule LEAD AUTHORS
States, with a relatively large enforcement, and proper age- Andrew Watson, MD, MS, FAAP
proportion of preadolescent appropriate heading techniques Jeffrey M. Mjaanes, MD, FAAP
participants. Although injuries may reduce the risk of concussion
occur in soccer, injury rates in youth soccer participants.
Encouraging athletes to report COUNCIL ON SPORTS MEDICINE AND
appear lower than those for many FITNESS EXECUTIVE COMMITTEE,
other contact sports and are subjective symptoms facilitates
2017–2018
particularly low in soccer players proper diagnosis and management.
Cynthia R. LaBella, MD, FAAP, Chairperson
younger than 12 years of age. 5. Other injury reduction strategies M. Alison Brooks, MD, FAAP
Pediatric health care providers for soccer include completion of Greg Canty, MD, FAAP
can feel comfortable with a PPE before the start of the Alex B. Diamond, DO, MPH, FAAP
season to identify any risk factors William Hennrikus, MD, FAAP
advocating for participation in
Kelsey Logan, MD, MPH, FAAP
soccer as a means of promoting for injury, proper hydration and Kody Moffatt, MD, FAAP
physical fitness and the wide- rest, modification of activities in Blaise A. Nemeth, MD, MS, FAAP
ranging benefits of exercise. hot and humid weather, use of K. Brooke Pengel, MD, FAAP
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10 FROM THE AMERICAN ACADEMY OF PEDIATRICSAndrew R. Peterson, MD, MSPH, FAAP CONSULTANTS
Paul R. Stricker, MD, FAAP ABBREVIATIONS
Nicholas M. Edwards, MD, MPH, FAAP
Avery D. Faigenbaum, EdD, FACSM AAP: American Academy of
Chris G. Koutures, MD, FAAP Pediatrics
LIAISONS J. Terry Parker, PhD, ATC ACL: anterior cruciate ligament
Donald W. Bagnall – National Athletic
FIFA: Fédération Internationale de
Trainers’ Association
Mark E. Halstead, MD, FAAP – American Football Association
Medical Society for Sports STAFF PPE: preparticipation evaluation
Medicine Anjie Emanuel, MPH
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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