As summer has become fall we remember the recent excitement of the World Cup 2018 and revel in the amazing athletes who play soccer or fútbol. It’s eye-opening to see and hear surgeons in the Operating Room doctors lounge speak about favorite players in the great European professional leagues, Mexico and South America.

Major League Soccer is now driving burgeoning interest as a “favored” American sport and having its most exciting season in history as its playoffs are just around the corner.  Behind all this interest is the complexity of the game and the athletes themselves. Famous non-soccer athletes now routinely express awe and mutual respect at the skills of soccer athletes, as well9.

These athletes are revered for their size, skill, speed, strength, endurance and balance which tend to all inform the player’s passing accuracy and degree of ball control that are most important to the high performance and success of these athletes17.

Soccer athletes rely on their lower extremities for a preponderance of the physical work required to excel in the sport. They maximally exert themselves. Some estimates have described the typical distance covered in elite players as 10-13 kilometers per game12.  Players in the Football Association Premier League make close to 700 turns in a game, with approximately 600 of them being 0–90 degrees2. The aerobic energy system is highly taxed in soccer due to its intermittent bursts with average and peak energy rates around 85% and 98% of maximal values10.

Common injuries

It has long been known that anterior cruciate ligament (ACL) injuries are common in soccer18 and this has led to an array of programs designed to prevent injury in soccer athletes3,6. The combined thigh/upper leg and ankle (36.5%) have more injury predominance than the knee (18.7%) in one expansive high school study over 2 seasons18. In a recent study of Spanish elite male and female soccer football players, hamstring strains and sports groin hernia cases were more frequent in men, whereas quadriceps strains, ACL ruptures and ankle injuries were more common in women11.

A study of Union of European Football Associations (UEFA) and other best European teams revealed:

  • Ninety-two percent of all muscle injuries affected the four major lower extremity muscle groups: hamstrings (37%), adductors (23%), quadriceps (19%), and calf muscles (13%)5.
  • Re-injuries caused longer time lost from play.

A second study in the same general elite or professional European soccer population revealed:

  • Muscle injury rates are increased due to intrinsic factors such as previous injury, older age, and kicking leg preponderance7.
  • Injury rates varied depending on the time of the season and match location.Another study recently showed that matches played within 5 days since the previous match leads to higher muscle injury rates over 14 years in professional footballers1.


Muscle functional magnetic resonance imaging has been used to detect differences in metabolic characteristics between different hamstring muscle bellies both at the time of first testing and over a period of follow-up15.

Ultrasonography (US) has now become a vital noninvasive tool for the diagnosis and prognosis of hamstring injuries in soccer players14. The US examination can classify muscle injuries as extrinsic or intrinsic injuries as well as contusions and lacerations4. Ultrasound has been described in an adjunctive fashion to aid muscle tear visualization in injections of corticosteroids and platelet-rich plasma as treatment for the potentiation of healing of these injuries13, although I’m not opining on the relative benefit of each. The US examination has been considered as an aide in return to play return to play (RTP) decisions in soccer athletes8,14.


Return to play

Return to play after leg muscle injuries in soccer players is difficult and can be fraught with indecisiveness due to the risk for re-injury if return is too fast and potential for loss of too much time in a sport that depends so vitally on the lower extremities16. RTP has variously been defined as ‘the moment a player has received criteria-based medical clearance and is mentally ready for full availability for match selection and/or full training’.

Van der Horst et al. described the following criteria for RTP16:

  • Medical staff clearance
  • Absence of pain on palpation
  • Absence of pain during strength and flexibility testing
  • Absence of pain during/after functional testing
  • Similar hamstring flexibility, performance on field testing, and psychological readiness.
  • RTP decisions should be based on shared decision-making primarily between the athlete, sports physician, athletic trainer, physical therapist, performance director and head coach.
  • Early re-injury can be especially morbid with a longer recovery than initial injury, so these decisions are not taken lightly.

There is a gamut of other injuries that are seen in soccer including gluteus, hernia and groin injuries, as well as foot and ankle injuries and issues of soccer shoe/boot fit and general foot and ankle care that are beyond the scope of this short description of the degree of dependence the soccer athlete has on his or her lower extremities or legs. Suffice to say, our favorite soccer athlete really is an amazing athlete and really using their legs, so we should cheer even more loudly when we see them glide along the pitch.

Team Co-Orthopaedic Surgeon, Los Angeles Football Club (LAFC)

Member at Large, AAOS Board of Directors



  1. Bengtsson H, Ekstrand J, Waldén M, Hägglund M. Muscle injury rate in professional football is higher in matches played within 5 days since the previous match: a 14-year prospective study with more than 130 000 match observations. Br J Sports Med. 2018 Sep;52(17):1116-1122. doi: 10.1136/bjsports-2016-097399. Epub 2017 Nov 3.
  2. Bloomfield, J., R. Polman, and P. O’Donoghue. Physical Demands of Different Positions in FA Premier League Soccer.  Sports Sci. Med. 6(1):63-70, 2007.
  3. De Ste Croix M, Hughes J, Ayala F, Taylor L, Datson N. Efficacy of Injury Prevention Training Is Greater for High-Risk vs Low-Risk Elite Female Youth Soccer Players. Am J Sports Med. 2018 Sep 18:363546518795677. doi: 10.1177/0363546518795677
  4. Draghi F, Zacchino M, Canepari M, Nucci P, Alessandrino F. Muscle injuries: ultrasound evaluation in the acute phase. J Ultrasound. 2013 May 8;16(4):209-14. doi: 10.1007/s40477-013-0019-8. eCollection 2013 May 8. Review.
  5. Ekstrand J, Hägglund M, Waldén M. Epidemiology of muscle injuries in professional football (soccer). Am J Sports Med. 2011 Jun;39(6):1226-32. doi: 10.1177/0363546510395879. Epub 2011 Feb 18.
  6. Gilchrist J, Mandelbaum BR, Melancon H, Ryan GW, Silvers HJ, Griffin LY, Watanabe DS, Dick RW, Dvorak J. A randomized controlled trial to prevent noncontact anterior cruciate ligament injury in female collegiate soccer players. Am J Sports Med. 2008 Aug;36(8):1476-83. doi: 10.1177/0363546508318188.
  7. Hägglund M, Waldén M, Ekstrand J. Risk factors for lower extremity muscle injury in professional soccer: the UEFA Injury Study. Am J Sports Med. 2013 Feb;41(2):327-35. doi: 10.1177/0363546512470634. Epub 2012 Dec 21.
  8. Kellis E, Galanis N, Chrysanthou C, Kofotolis N. Use of Ultrasound to Monitor Biceps Femoris Mechanical Adaptations after Injury in a Professional Soccer Player. J Sports Sci Med. 2016 Feb 23;15(1):75-9. eCollection 2016 Mar.
  9. Kobe Bryant talks soccer, friendship with Lionel Messi and Ronaldinho. Jun 30, 2017 Accessed September 17, 2018.
  10. Krustrup, P., M. Mohr, A. Steensberg, J. Bencke, M. Kjær and J. Bangsbo. Muscle and Blood Metabolites during a soccer game: Implications for sprint performance.  Sci. Sports Exerc., 38: 1165-1174, 2006.
  11. Larruskain J, Lekue JA, Diaz N, Odriozola A, Gil SM. A comparison of injuries in elite male and female football players: A five-season prospective study. Scand J Med Sci Sports. 2018 Jan;28(1):237-245. doi: 10.1111/sms.12860. Epub 2017 Mar 27.
  12. Mascio, M., and P.S. Bradley. Evaluation of the most intense high-intensity running period in English FA premier league soccer matches.  Strength Cond. Res. 27(4):909-915, 2013.
  13. Park PYS, Cai C, Bawa P, Kumaravel M. Platelet-rich plasma vs. steroid injections for hamstring injury-is there really a choice? Skeletal Radiol. 2018 Sep 17. doi: 10.1007/s00256-018-3063-9. [Epub ahead of print]
  14. Petersen J, Thorborg K, Nielsen MB, Skjødt T, Bolvig L, Bang N, Hölmich P. The diagnostic and prognostic value of ultrasonography in soccer players with acute hamstring injuries. Am J Sports Med. 2014 Feb;42(2):399-404. doi: 10.1177/0363546513512779. Epub 2013 Dec 11.
  15. Schuermans J, Van Tiggelen D, Danneels L, Witvrouw E. Susceptibility to Hamstring Injuries in Soccer: A Prospective Study Using Muscle Functional Magnetic Resonance Imaging. Am J Sports Med. 2016 May;44(5):1276-85. doi: 10.1177/0363546515626538.
  16. van der Horst N, Backx F, Goedhart EA, Huisstede BM; HIPS-Delphi Group. Return to play after hamstring injuries in football (soccer): a worldwide Delphi procedure regarding definition, medical criteria and decision-making. Br J Sports Med. 2017 Nov;51(22):1583-1591. doi: 10.1136/bjsports-2016-097206. Epub 2017 Mar 30.
  17. Wilson RS, David GK, Murphy SC, Angilletta MJ Jr, Niehaus AC, Hunter AH, Smith MD. Skill not athleticism predicts individual variation in match performance of soccer players. Proc Biol Sci. 2017 Dec 13;284(1868). pii: 20170953. doi: 10.1098/rspb.2017.0953.
  18. Yard EE, Schroeder MJ, Fields SK, Collins CL, Comstock RD. The epidemiology of United States high school soccer injuries, 2005-2007. Am J Sports Med. 2008 Oct;36(10):1930-7. doi: 10.1177/0363546508318047.

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