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Knee injuries in soccer

by Martin Krause

  Soccer Aerial North Sydney Physiotherapy



Knee injuries are quite prevalent in soccer. Injuries can be separated into 'contact' and 'non-contact' injuries. Non-contact injuries include the 'triad' of the inside cartilage (medial meniscus) damage, along with the medial collateral ligament (connecting the two bones on the inside) and anterior cruciate ligament (ACL). There appears to be a higher prevalence of this injury in young women. Indeed, increased susceptability to ACL injuries has been found in adolescent girls with reduced hamstring strength, who also have also been shown to have reduced hip abduction strength (Wild et al 2013, Medicine & Science in Sports & Exercise, 45, 3, 497–505). However, several health benefits have been identified with the participation in soccer, amongst which have even included significant reductions in blood pressure in middle aged hypertensive men (systolic and diastolic blood pressures decreased (P < 0.01) over 6 months from 151 ± 10 to 139 ± 10 mm Hg and from 92 ± 7 to 84 ± 6 mm Hg) (Krustrup et al 2013, Medicine & Science in Sports & Exercise, 45, 3, 553–561). Additional benefits include psychological ones representing aspects such as 'a sense of belonging' which occurs through socialisation. Moreover, individual psychological traits will influence a persons reponses as they go through the 'stages' of injury and recovery.

Soccer Knee Valgus North Sydney Physiotherapy soccer dribbling North Sydney Physiotherapy

Biomechanics of the Knee

Investigations have shown that as the knee transitions to weight bearing at low knee flexion angles (15-30º), there is anterior (forward) translation of the tibia (shin bone) to the femur (thigh bone), which is normally restrained by the ACL (Schultz et al 2011 Med Sc Sp Ex, 43, 2, 287-295). These knee flexion angles are a common angle for aspects of soccer such as kicking, dribbling and fast sideways 'cutting' actions. Moreover, during side step cutting action, females have been shown to exhibit 20% higher knee adductor moments and nearly twice the knee valgus when compared with males (Sigward et al 2012, Med Sc Sp Ex, 44, 8, 1497-1503). Additional problems may include patellofemoral (anterior knee) pain in which the ability to produce knee extensor torques are reduced and the knee muscle EMG activity is eratic (Rathleff et al 2013, Med Sc Sp Ex, 45, 9, 1730-1739)

Mechanism of injury

These injuries usually occur as a result of a fast movement with a degree of rotation and pivoting involved. The foot and lower leg turn outward, relative to the upper leg turning inward, creating a gapping force on the inside of the knee. This is commonly referred to as a valgus force. People with poor hip control are thought to be more vulnerable to an uncontrolled valgus force. The combination of knee valgus strain (51Nm) and hip internal rotation strain (25.9Nm) has been demonstrated to increase the strain on the ACL by 0.115, high enough to cause it to rupture (Shin et al 2011, Med Sc Sp Ex, 43, 8, 1484-1491), as the rupture strain lies between 0.09 -> 0.  Additionally, in females with abnormal hip kinematics, femoral (thigh - hip) internal rotation has been demonstrated to increase patellofemoral (knee cap) hydrostatic pressure and octahedral shear stress (Liao et al 2016, Med Sc Ex Sp, 47, 9, 1775-1780)

soccer one on one North Sydney Physiotherapy

Contrasting hip strength and control during landing in women.

It has been shown that individuals with reduced hip strength have greater pelvic angular displacement, peak velocity, total angular excursion and higher muscle activation of the trunk and gluteal muscles than stronger individuals (Popovich & Kulig 2012 Med Sc Sp Ex, 44, 1,146-153). Lack of control of the inward movement of the knee has been demonstrated to improve with functional hip abductor and external rotator training (Baldon et al 2012 Med Sc Sp Ex, 44, 1, 135-145). They also employed core stabilising exercises for the abdominal region. However, static core stabilising exercises have not been shown to improve knee loading (Jamison et al 2012, Med Sc Sp Ex, 44, 10, 1924-1934). Therefore, dynamic trunk exercises using pertubations of movement need to be incorporated into a rehabilitation program. Plevic floor exericses are also recommended by us as the obturator internis muscle is a hip lateral rotator whose myofascial membrane is continuous with the pelvic floor.

Dry Needling 

Dry Needling has been shown to result in significant improvements of muscular endurance of knee extensors and hip flexion that persisted 4 wk posttreatment as well as a short-term improvement of muscular endurance of knee flexors in the intragroup analysis of soccer players. Compared with placebo, DN showed a significant effect on hip flexion that persisted 4 wk posttreatment. Compared with a nontreatment control, DN also significantly improved maximum force of knee extensors also 4 wk posttreatment. Compared with a nontreatment control, placebo laser combined with water pressure massage resulted in a small but statistically significant improvement of hip flexion range of motion at treatment end and 4 wk posttreatment (Haser et al 2017 Medicine & Science in Sports & Exercise . 49(2):378-383)... further information...

Foot pronation and knee valgus

The arch of the foot comprises several bones. One of the main joints in the arch is the talo-navicular joint which is a 'ball & socket' joint, meaning that it is designed to allow a lot of rotational movement. The talus sits under the tibia (shin bone) and hence influences it's movement. 

Tibial rotation is accompanied ankle inversion/eversion and mid foot inversion/eversion

Combinations of shoes and orthotics can greatly influence the tibial rotation.

Anterior cruciate ligament (ACL) and the menstrual cycle

The ACL is designed to prevent forward shearing of the shin bone (tibia) on the thigh bone (femur).  Anterior knee laxity (AKL) and hyperextension of the knees were shown to be significant predictors of anterior tibial translation (ATT) in both males and females. Interestingly the restraining structures to knee hyperextension are the posterior cruciate ligament (PCL) and popliteus muscle, suggesting that the knee in non weight bearing is in a relative posterior position and hence allows for greater total anterior excursion of the tibia. Notably, if a females AKL changes as much as 3mm across her menstrual cycle the ATT changes by 2mm which represented a change of approx 30% in mean magnitude of the ATT (Schultz et al 2011 Med Sc Sp Ex, 43, 2, 287-295). Furthermore, in another investigation, the same authors demonstrated increased absolute and relative magnitudes of multiplanar knee laxity changes. These were seen as increased valgus coupled with relatively greater external rotation of the tibia, making the knee more susceptible to injury on ground contact and early in the landing phase (Schultz et al 2012 Med Sc Sp Ex, 44, 5, 900-909)

Muscle activation around the knee after injury affects cortical representation of muscles in the brain

The representation of the knee muscles in the brain

Transcortical muscle stimulation imaging (Abrahao Fontes Baptista 2014)

Muscle activation around the patella and the menstrual cycle

The initial firing rate is lower in the VMO (vastus medialis oblique) compared with VM (vastus medialis) in women not men. The firing rate is affected by the menstrual cycle, showing increases in initial firing during the early follicular phase through tp the late luteal phase. The initial firing was lower in VMO compared to VM during ovulatory and midluteal phases (Tenan et al 2013, Ex Sc Sp Ex, 45, 11, 2151-2157). This could play a bearing on anterior knee pain due to an increased lateral gliding of the patella over the femur, leading to patellofemoral syndrome.

Menstruation muscle stretch reflex

Fatigue, gait and neuromuscular asymmetries after acute ACL rupture

Patients have been shown to have reduced peak knee moments for both flexion and extension in the injured knee. However, the size of the reduction in extensor moment was greater than reductions in flexor moment, when compared between limbs (Gardinier et al 2012, Med Sc Sp Ex, 44, 8, 1490-1496).

A series of squats, bilateral height jumping, and single limb landing exerices were used to induce fatigue in a population of post surgical ACL repaired males. Interestingly, altered joint biomechanics was seen, even at moderate levels of fatigue (<50%). Interestingly, little inter-limb variation was see, except for a reduction in hip extensor moment, which may represent a compensatory strategy to reduce the demand on the knee when jumping from a height. Both knees landed in more abduction (outward positioning) as fatigue set in (Webster et al 2011, Med Sc Sp Ex, 44, 5, 910-916).

Neuromuscular function during a forward lunge in meniscectomized patients

Researchers have demonstrated increased muscle coactivation, reduced range of motion, and increased rate of loading in the operated limb when compared to the other side (Thorlund et al 2012, Med Sc Sp Ex, 44, 7, 1358-1365). This coactivation was mainly the result of increased hamstring muscle activity. Another, investigation by the same researchers, during stair descending demonstrated reduced medial versus lateral muscular activity in the operated leg (Thorlund et al 2011, Med Sc Sp Ex, 43, 7, 1272 - 1279).  In a 2 year longitudinal study, post medial meniscectomy, it was shown that those subjects who underwent surgery had greater eccentric muscle strength deficit (8% and 9% hamstrings quadriceps resp) and increased external knee adduction moment. The reduction in these mitigating factors are considered significant in that they may be a contributing factors to the early onset of osteoarthritis (Hall et al 2013, Med Sc Sp Ex, 45, 11, 2036-2043).

Stages of injury

  • Denial

Athletes begin an internal dialogue trying to convince themselves that it's not that bad. They try to get up and run or jump or convince themselves that it will be better in a couple of days. In extreme cases, athletes pretend there is no injury.

  • Anger

 "Why me?" or "Why now?"

  • Bargaining 

Athletes accept the injury and endure the pain, but they try to ignore it or overcome it by adapting their training to avoid the injured area. Generally performance drops and compensatory strategies create imbalance and over loading of other structures or body parts.

  • Depression

If your training and goals were well planned out, your injury can have a greater impact, because it's more obvious what's missing. Hormonal considerations such as the lack of endorphines from training also play a critical role.

  • Acceptance

For rehabilitation to be effective, this is the stage you need to get to. The preceding stages are completely natural and understandable. Recognize them for what they are. You can start working on your rehab right away, even while you are going through the other stages.

Treatment and exercises for knee rehabilitation

Whilst working in Switzerland, with professional soccer players, from the Italian Series A and German Bundesliga, I noted that soccer players have relatively tight hamstrings, adductors and hip flexors, and well developed calfs, quadriceps, hamstrings and gluteal muscles. Investigations have demonstrated that localised application of vibration can improve passive knee extension in women (Bakhtiary et al 2011, AJP, 57, 165-171). Studies have shown that women's hip muscles can atrophy after an injury as simple as an ankle sprain, due primarily to injury-caused limping or using crutches. Any hip or core muscle weakness, when combined with a woman's biomechanics, can be detremental to a female athlete returning to the soccer field. Proper rehabilitation is critical to coming back from an injury stronger and healthier. From the previous discussion, it would appear that neuromuscular balance and control are exceedingly important factors in the rehabilitation of the knee. Moreover, hip-back-pelvic-foot dynamic control are critical for a return to function and sport.

Evasive side stepping

It has been demonstrated that evasive side stepping during sport, against an opponent, activates different postures and knee moments (Lee et al 2013, Med Sc Sp Ex,45, 9, 1740-1748). Hence, stimuli realism needs to be incorporated into ACL rehabilitation programs in order to activate visual-perceptual-motor skill complexity that is required during side stepping.

Medial - Lateral Stability

Engagement of the hamstrings to extend the knee

Core Stability

Hip Stabilisation

On field rehabilitation should include

  • forward - backward running
  • sideways running - foot to foot, foot over foot
  • running in ever smaller circles
  • figure of 8 running
  • running with ball and doing tricks with ball
  • soccer drills

20 February 2017


Trending @ Back in B Physio

  • Thu 22 Dec 2016

    Ehlers Danlos Syndrome

    Is your child suffering Ehlers Danlos Syndrome? Hypermobile joints, frequent bruising, recurrent sprains and pains? Although a difficult manifestation to treat, physiotherapy can help. Joint Hypermobility Syndrome (JHS) When joint hypermobility coexists with arthralgias in >4 joints or other signs of connective tissue disorder (CTD), it is termed Joint Hypermobility Syndrome (JHS). This includes conditions such as Marfan's Syndrome and Ehlers-Danlos Syndrome and Osteogenesis imperfecta. These people are thought to have a higher proportion of type III to type I collagen, where type I collagen exhibits highly organised fibres resulting in high tensile strength, whereas type III collagen fibres are much more extensible, disorganised and occurring primarily in organs such as the gut, skin and blood vessels. The predominant presenting complaint is widespread pain lasting from a day to decades. Additional symptoms associated with joints, such as stiffness, 'feeling like a 90 year old', clicking, clunking, popping, subluxations, dislocations, instability, feeling that the joints are vulnerable, as well as symptoms affecting other tissue such as paraesthesia, tiredness, faintness, feeling unwell and suffering flu-like symptoms. Autonomic nervous system dysfunction in the form of 'dysautonomia' frequently occur. Broad paper like scars appear in the skin where wounds have healed. Other extra-articular manifestations include ocular ptosis, varicose veins, Raynauds phenomenon, neuropathies, tarsal and carpal tunnel syndrome, alterations in neuromuscular reflex action, development motor co-ordination delay (DCD), fibromyalgia, low bone density, anxiety and panic states and depression. Age, sex and gender play a role in presentaton as it appears more common in African and Asian females with a prevalence rate of between 5% and 25% . Despite this relatively high prevalence, JHS continues to be under-recognised, poorly understood and inadequately managed (Simmonds & Kerr, Manual Therapy, 2007, 12, 298-309). In my clinical experience, these people tend to move fast, rely on inertia for stability, have long muscles creating large degrees of freedom and potential kinetic energy, resembling ballistic 'floppies', and are either highly co-ordinated or clumsy. Stabilisation strategies consist of fast movements using large muscle groups. They tend to activities such as swimming, yoga, gymnastics, sprinting, strikers at soccer. Treatment has consisted of soft tissue techniques similar to those used in fibromyalgia, including but not limited to, dry needling, myofascial release and trigger point massage, kinesiotape, strapping for stability in sporting endeavours, pressure garment use such as SKINS, BSc, 2XU, venous stockings. Effectiveness of massage has been shown to be usefull in people suffering from chronic fatigue syndrome (Njjs et al 2006, Man Ther, 11, 187-91), a condition displaying several clinical similarities to people suffering from EDS-HT. Specific exercise regimes more attuned to co-ordination and stability (proprioception) than to excessive non-stabilising stretching. A multi-modal approach including muscle energy techniques, dry needling, mobilisations with movement (Mulligans), thoracic ring relocations (especially good with autonomic symptoms), hydrotherapy, herbal supplementaion such as Devils Claw, Cats Claw, Curcumin and Green Tee can all be useful in the management of this condition. Additionally, Arnica cream can also be used for bruising. Encouragment of non-weight bearing endurance activities such as swimming, and cycling to stimulate the endurance red muscle fibres over the ballistic white muscles fibres, since the latter are preferably used in this movement population. End of range movements are either avoided or done with care where stability is emphasized over mobility. People frequently complain of subluxation and dislocating knee caps and shoulders whilst undertaking a spectrum of activities from sleeping to sporting endeavours. A good friend of mine, Brazilian Physiotherapist and Researcher, Dr Abrahao Baptista, has used muscle electrical stimulation on knees and shoulders to retrain the brain to enhance muscular cortical representation which reduce the incidence of subluxations and dislocations. Abrahao wrote : "my daughter has a mild EDS III and used to dislocate her shoulder many times during sleeping.  I tried many alternatives with her, including strenghtening exercises and education to prevent bad postures before sleeping (e.g. positioning her arm over her head).  What we found to really help her was electrostimulation of the supraspinatus and posterior deltoid.  I followed the ideas of some works from Michael Ridding and others (Clinical Neurophysiology, 112, 1461-1469, 2001; Exp Brain Research, 143, 342-349 ,2002), which show that 30Hz electrostim, provoking mild muscle contractions for 45' leads to increased excitability of the muscle representation in the brain (at the primary motor cortex).  Stimulation of the supraspinatus and deltoid is an old technique to hemiplegic painful shoulder, but used with a little different parameters.  Previous studies showed that this type of stimulation increases brain excitability for 3 days, and so we used two times a week, for two weeks.  After that, her discolcations improved a lot.  It is important to note that, during stimulation, you have to clearly see the humerus head going up to the glenoid fossa" Surgery : The effect of surgical intervention has been shown to be favourable in only a limited percentage of patients (33.9% Rombaut et al 2011, Arch Phys Med Rehab, 92, 1106-1112). Three basic problems arise. First, tissues are less robust; Second, blood vessel fragility can cause technical problems in wound closure; Third, healing is often delayed and may remain incomplete.  Voluntary Posterior Shoulder Subluxation : Clinical Presentation A 27 year old male presented with a history of posterior shoulder weakness, characterised by severe fatigue and heaviness when 'working out' at the gym. His usual routine was one which involved sets of 15 repetitions, hence endurance oriented rather than power oriented. He described major problems when trying to execute bench presses and Japanese style push ups. In a comprehensive review of 300 articles on shoulder instability, Heller et al. (Heller, K. D., J. Forst, R. Forst, and B. Cohen. Posterior dislocation of the shoulder: recommendations for a classification. Arch. Orthop. Trauma Surg. 113:228-231, 1994) concluded that posterior dislocation constitutes only 2.1% of all shoulder dislocations. The differential diagnosis in patients with posterior instability of the shoulder includes traumatic posterior instability, atraumatic posterior instability, voluntary posterior instability, and posterior instability associated with multidirectional instability. Laxity testing was performed with a posterior draw sign. The laxity was graded with a modified Hawkins scale : grade I, humeral head displacement that locks out beyond the glenoid rim; grade II, humeral displacement that is over the glenoid rim but is easily reducable; and grade III, humeral head displacement that locks out beyond the glenoid rim. This client had grade III laxity in both shoulders. A sulcus sign test was performed on both shoulders and graded to commonly accepted grading scales: grade I, a depression <1cm: grade 2, between 1.5 and 2cm; and grade 3, a depression > 2cm. The client had a grade 3 sulcus sign bilaterally regardless if the arm was in neutral or external rotation. The client met the criteria of Carter and Wilkinson for generalized liagmentous laxity by exhibiting hyperextension of both elbows > 10o, genu recurvatum of both knees > 19o, and the ability to touch his thumbto his forearm Headaches Jacome (1999, Cephalagia, 19, 791-796) reported that migraine headaches occured in 11/18 patients with EDS. Hakim et al (2004, Rheumatology, 43, 1194-1195) found 40% of 170 patients with EDS-HT/JHS had previously been diagnosed with migraine compared with 20% of the control population. in addition, the frequency of migraine attacks was 1.7 times increased and the headache related disability was 3.0 times greater in migraineurs with EDS-HT/JHS as compared to controls with migraine (Bendick et al 2011, Cephalgia, 31, 603-613). People suffering from soft tissue hypermobility, connective tissue disorder, Marfans Syndrome, and Ehler Danlos syndrome may be predisposed to upper cervical spine instability. Dural laxity, vascular irregularities and ligamentous laxity with or without Arnold Chiari Malformations may be accompanied by symptoms of intracranial hypotension, POTS (postural orthostatic tachycardia syndrome), dysautonomia, suboccipital "Coat Hanger" headaches (Martin & Neilson 2014 Headaches, September, 1403-1411). Scoliosis and spondylolisthesis occurs in 63% and 6-15% of patients with Marfans syndrome repsectively (Sponseller et al 1995, JBJS Am, 77, 867-876). These manifestations need to be borne in mind as not all upper cervical spine instabilities are the result of trauma. Clinically, serious neurological complications can arise in the presence of upper cervical spine instability, including a stroke or even death. Additionally, vertebral artery and even carotid artery dissections have been reported during and after chiropractic manipulation. Added caution may be needed after Whiplash type injuries. The clinician needs to be aware of this possibility in the presence of these symptoms, assess upper cervical joint hypermobility with manual therapy techniques and treat appropriately, including exercises to improve the control of musculature around the cervical and thoracic spine. Atlantoaxial instability can be diagnosed by flexion/extension X-rays or MRI's, but is best evaluated by using rotational 3D CT scanning. Surgical intervention is sometimes necessary. Temperomandibular Joint (TMJ) Disorders The prevelence of TMJ disorders have been reported to be as high as 80% in people with JHD (Kavucu et al 2006, Rheum Int., 26, 257-260). Joint clicking of the TMJ was 1.7 times more likely in JHD than in controls (Hirsch et al 2008, Eur J Oral Sci, 116, 525-539). Headaches associated with TMJ disorders tend to be in the temporal/masseter (side of head) region. TMJ issues increase in prevelence in the presence of both migraine and chronic daily headache (Goncalves et al 2011, Clin J Pain, 27, 611-615). I've treated a colleague who spontaneously dislocated her jaw whilst yawning at work one morning. stressful for me and her! Generally, people with JHD have increased jaw opening (>40mm from upper to lower incisors). Updated 18 May 2017  Read More
  • Fri 09 Dec 2016

    Physiotherapy with Sharna Hinchliff

    Physiotherapy with Sharna Hinchliff    Martin is pleased to welcome the very experienced physiotherapist Sharna Hinchliff to Back in Business Physiotherapy for one on one physiotherapy sessions with clients in 2017.  Sharna is a passionate triathelete and mother and has had several years experience working locally and internationally (New York and London) in the field of physiotherapy. Originally from Western Australia, Sharna graduated from the world renowned Masters of Manipulative Physiotherapy at Curtin University. read more Read More
  • Mon 07 Nov 2016

    Pilates – with Brunna Cardoso

    Pilates – with Brunna Cardoso Martin is pleased to welcome the bubbly Brunna Cardoso to Back in Business Physiotherapy for Pilates Classes in February 2017.  Brunno is an experienced pilates instructor and has had several years experience training with pilates instructors in Brazil. Read more Read More

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Updated : 10 May 2014

No responsibility is assumed by Back in Business Physiotherapy for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or ideas contained in the material in this and it's related websites. Because of rapid advances in the medical sciences, the author recommends that there should be independent verification of diagnoses and exercise prescription. The information provided on Back in Business Physiotherapy is designed to support, not replace, the relationship that exists between a patient/site visitor and their treating health professional.

Copyright Martin Krause 1999 - material is presented as a free educational resource however all intellectual property rights should be acknowledged and respected