Number of previous ankle sprains a latent risk factor for recurrent ankle sprain in young soccer players

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1 J Phys Fitness Sports Med, 3(1): (2014) DOI: /jpfsm JPFSM: Regular Article Number of previous ankle sprains a latent risk factor for recurrent ankle sprain in young soccer players Genki Futatsubashi 1*, Syusaku Sasada 2, Hiroyuki Ohtsuka 3 and Tomoyoshi Komiyama 1,4 1 Division of Health and Sport Education, The United Graduate School of Education, Tokyo Gakugei University, 1-33 Yayoi-cho, Inage-ku, Chiba , Japan 2 Division of Behavioral Development, Department of Developmental Physiology, National Institute for Physiological Sciences, 38 Nishigonaka Myodaiji, Okazaki, Aichi , Japan 3 Department of Physical Therapy, Health Sciences University of Hokkaido, 1757 Kanazawa, Tobetsu-cho, Ishikari-gun, Hokkaido , Japan 4 Department of Education, Chiba University, Chiba, 1-33 Yayoi-cho, Inage-ku, Chiba , Japan Received: September 17, 2013 / Accepted: January 24, 2014 Abstract In the present study, the aim was to determine whether a history of ankle sprain during the junior (JUN; age < 12 years) playing years of soccer players could predict the occurrence of ankle sprain in their junior youth (JY; age < 13, 14, and 15 years) playing years. Therefore, we administered a questionnaire survey to 1,361 players belonging to 28 JY soccer teams. Analyses of the participants answers indicated that 57.0% of the players sustained ankle sprains during their JUN playing years and 64.0% of the players sustained ankle sprains during their JUN and JY playing years. Players with a history of 5 ankle sprains had a higher occurrence rate of sprains in their JY years as compared to players with no history of ankle sprains. The odds ratio (OR), calculated using logistic regression analysis based on the number of ankle sprains sustained during the JUN playing years, was highest for players with 5 sprains compared to those with 2 or 3 sprains during the JUN playing years. To reduce the occurrence rate of ankle sprains for players in the JY category, effective screening processes, prevention measures, and rehabilitation programs for ankle sprains during the JUN playing years should be established. Keywords : ankle sprain, soccer, young athletes, transition period, recurrence Introduction The ankle joint is a common injury site among pediatric and adolescent soccer players 1-7). Ankle sprains are a significant problem for adult, junior youth (JY) (U13, U14 and U15: age < 13, 14 and 15 years, respectively), and junior (JUN) (U7-U12: from ages less than 7 to less than 12 years) category soccer players. An ankle sprain can cause soccer players to sit out games or training sessions for several days or even weeks. Full recovery often takes considerably more time than expected in injured players. In addition, an ankle sprain sustained during childhood and adolescence could result in subsequent deterioration and chronic ankle instability 8). Therefore, an investigation of the risk factors for ankle sprain and methods for preventing recurrent ankle sprains in young players is important. Various risk factors have been investigated with the aim of preventing initial or recurrent ankle sprains. Studies have shown that an ankle sprain history is the most *Correspondence: gen_futatsubashi@graduate.chiba-u.jp important intrinsic predictor for ankle sprain recurrence in adult soccer players 9-13). In a prospective cohort study on adult male soccer players, Ekstrand and Tropp 9) found that the injury rate was 2.3 times higher in soccer players with a history of ankle sprain than in those without an ankle sprain history. Arnason et al. 10) also found that adult male soccer players with an ankle sprain history had a higher risk of subsequent ankle sprains than those without an ankle sprain history. Engebretsen et al. 11) showed that even a single previous acute ankle sprain could be a significant risk factor for recurrent acute ankle sprains in male soccer players, and that the risk of recurrent ankle sprains increased with the number of previous injuries. In particular, players who sustained >5 ankle sprains showed a definitely higher risk of recurrence. Thus, ankle sprain recurrence is strongly dependent on ankle sprain history even in young soccer players 12,14-15). To promote the sound growth and development of JUN and JY soccer players, an investigation of the effect of previous injuries sustained during the JUN playing years on injury recurrence during the subsequent JY playing years is crucial in terms of preventive injury prevention

2 140 JPFSM : Futatsubashi G, et al. screening. Kucera et al. 12) indicated that compared with athletes with no previous injuries, players aged years with a single previous injury had a two-fold greater risk of recurrent injury, whereas those with 2 previous injuries had a three-fold greater risk of recurrent injury. However, to date, analyses of risk factors for ankle sprain in JUN soccer players and differences in those risk factors between JUN and JY soccer players have not been performed despite the sizeable number of children engaged in soccer. Thus, there is no tangible evidence showing the association between a history of ankle sprain in young JUN soccer players and the recurrence rate of ankle sprains in JY soccer players. We hypothesized that the occurrence of ankle sprains in young JY soccer players is associated with the number of previous ankle sprains sustained during the JUN playing years. Therefore, we investigated the history of ankle sprains in JY soccer players, and then analyzed the relationship between the occurrence of ankle sprains sustained during the JY playing years and those sustained during the JUN playing years. Methods Participants. A total of 6,158 JY soccer players and 90 teams were registered with the Tokyo Junior Youth Club Association of Soccer in the 2010 season and divided into seven regions across Tokyo. First, we randomly selected 45 teams from these seven regions. We deliberately avoided choosing more teams from one level than another. Second, a total of 2,180 JY soccer players from 28 teams were invited to participate in the study. However, 17 teams did not approve or respond to this investigation request. We provided detailed explanations of the purpose of the present study to the directors and coaches before obtaining consent to participate in this survey. Furthermore, given that the players were juveniles, we explained the purpose of the present study to their parents. The parents of 1,565 players allowed their children to participate in this survey, whereas 615 declined. The questionnaire recovery rate was 71.8%. Sixty-seven players failed to complete the questionnaire; therefore, the valid response rate was 95.7%. In addition, 137 players reported ankle sprains sustained by causes other than soccer, and their responses were excluded to appropriately evaluate only soccer-related ankle sprains (Fig. 1). Thus, our final total reflects answers from 1,361 players (2,722 ankles) from 28 teams (U13, n = 531; U14, n = 411; and U15, n = 419). Survey Questionnaire. This study aimed to investigate ankle sprains that resulted in players sitting out practices or games. In the present study, ankle sprain was defined as an injury in which the ligaments of the ankle are partially or completely torn due to sudden stretching as a result of sudden twisting of the ankle. We attempted to identify the number of left and right ankle sprains during the JUN and JY playing years. We then determined whether the players who sustained ankle sprains during their JUN playing years had recurrent ankle sprains during their JY playing years. We instructed the JY players to complete the questionnaire with the help of their parents to avoid inaccurate recollections (Table 1). Junior Youth team (U13 15 category) Invited to this study n = 2180/6158 players (28/90 teams) Response to the invitation Players participating in the questionnaire survey n = 1565 Declined invitation (no consent for parents) n = 615 (recovery rate: 71.8%) Excluded Ankle sprain by other causes (not soccer) n = 137 Excluded Incomplete answers on questionnaire n = 67 (response rate: 95.7%) Total participation for 1361 players (2722 ankles) U13: 531 players (1062 ankles) U14: 411 players (822 ankles) U15: 419 players (838 ankles) Fig. 1 Flowchart showing the progression of the number of players participating in the survey.

3 JPFSM: Risk of recurrent ankle sprain in young soccer players 141 Table 1. Questionnaire concerning ankle sprains 1) Have you experienced an "ankle sprain" during the JUN (U12) soccer playing years? Left Ankle Right Ankle 1. 5 ankle sprains 1. 5 ankle sprains ankle sprains ankle sprains 3. Only 1 ankle sprain 3. Only 1 ankle sprain 4. Other causes 4. Other causes 5. No ankle sprains 5. No ankle sprains 2) Have you experienced an "ankle sprain" during the JY (U13 15) soccer playing years? Left Ankle Right Ankle 1. 5 ankle sprains 1. 5 ankle sprains ankle sprains ankle sprains 3. Only 1 ankle sprain 3. Only 1 ankle sprain 4. Other causes 4. Other causes 5. No ankle sprains 5. No ankle sprains * Ankle sprain was defined as an injury in which the ligaments of the ankle were partially or completely torn due to sudden stretching as a result of sudden twisting of the ankle. Statistical Analysis. The relationships between ankle sprain episodes and age were analyzed using the χ 2 test. In addition, ratios were obtained by dividing the number of ankle sprains sustained during the JUN playing years by the difference in the number of recurrent ankle sprains experienced between the JUN and JY soccer players. The values were compared with those of a reference group (those with no reported ankle sprains during the JUN playing years) using logistic regression analysis 16). To investigate the effect of ankle sprains sustained during the JUN playing years on the occurrence of ankle sprains during the JY playing years, the odds ratios (ORs) of the JY category players with and those without ankle sprains during their JUN playing years and their 95% confidence intervals (CI) with the number of ankle sprains sustained during JUN playing years were calculated. Statistical analysis was performed using the SPSS software (SPSS, version 20.0, Chicago, IL, USA). Results Fig. 2a shows that of all the players, 57.0% sustained ankle sprains during their JUN playing years (left) and 64.0% sustained ankle sprains during both their JUN and JY playing years (right). We found that 36.7% (U13), 39.2% (U14), and 51.1% (U15) of the players sustained bilateral ankle sprains over the total time they played soccer (Fig. 2b). The ratio of players with bilateral ankle sprains significantly increased with age (p < 0.001). Fig. 3 shows the number of ankle sprains in the JY players. The ratio of players with 5 ankle sprains also increased significantly with age (p < 0.001) as follows: 8.9% (U13), 10.7% (U14), and 24.8% (U15). Table 2 summarizes the effect of ankle sprains sustained during the JUN playing years on the incidence of their occurrence during the JY playing years. The players of all ages who did not sustain ankle sprains during their JUN years tended not to sustain ankle sprains during their JY years. The ORs for U13, U14, and U15 are all statistically significant. As shown in Fig. 4, the OR classified by the number of ankle sprains sustained during the JUN playing years was higher in players with 5 ankle sprains (OR, 17.3; CI, ) than in those with 2 or 3 ankle sprains (OR, 7.3; CI, ) or those with only a single ankle sprain (OR, 1.6; CI, ). Discussion The main findings of the present study are that >50% of JY players sustained ankle sprains and that players who sustained ankle sprains during their JUN playing years tended to have recurrent ankle sprains during their JY playing years. The rate and number of recurrent sprains clearly increased with age during the JY years. In addition, more importantly, the incidence rate of bilateral ankle sprains increased with age. We found that bilateral ankle sprains tended to increase with age for JY soccer players (Fig. 2). In addition, the

4 142 JPFSM : Futatsubashi G, et al. Table 2. Relationship between previous ankle sprains sustained during junior (U12, age 12 years or under) category soccer activities and the occurrence of ankle sprains during junior youth category soccer activities. Odds ratios between those with and without ankle sprains are described. Junior (U12) Ankle sprain (+) No ankle sprain (-) Odds ratio U15 (n = 838 ankles) Ankle sprain (+) No ankle sprain (-) U14 (n = 822 ankles) Ankle sprain (+) No ankle sprain (-) U13 (n = 1062 ankles) Ankle sprain (+) No ankle sprain (-) U13 15 (n = 2722 ankles) Ankle sprain (+) No ankle sprain (-) A JUN category Sum of JUN and JY categories No % Ankle sprain % No % Ankle sprain % n = 1361 players B U % 14.3% 7.2% 27.4% U % 13.6% 8.3% 38.9% U % 14.5% 8.5% 40.3% 0% 20% 40% 60% 80% 100% Bilateral Unilateral (right) Unilateral (left) No ankle sprains *** P < Fig. 2 A: Proportion of players with ankle sprains among the junior (JUN; left) category players and the sum of the ankle sprains occurring in both the JUN and junior youth (JY; right) categories. B: Bar chart of bilateral (black bars), right unilateral (dark gray), left unilateral (medium gray), and no ankle sprains (light gray) during playing years at the U13, U14, and U15 levels (age < 13, 14, and 15 years, respectively). *** P < number of players with 5 ankle sprains steadily increased for U15 players (Fig. 3). As age increases, workout duration and intensity as well as training or game frequency increase, which leads to a high rate of recurrent and bilateral ankle sprains in JY players (Fig. 2). Price et al. 7) indicated that the incidence of injury increased linearly with age and implied that this could be due to increased competitiveness at the U17 and U19 levels and increased exposure. Our findings regarding ankle sprains may strongly support this notion even for JY players. Several studies have indicated that a history of ankle sprain was a crucial risk factor for recurrent ankle sprain in adult 10-11,17-19) and young 12,14) soccer players. Engebretsen et al. 11) carried out a prospective cohort study inves-

5 JPFSM: Risk of recurrent ankle sprain in young soccer players 143 n = 2722 ankles U % 23.0% 13.8% 38.3% U % 23.4% 16.1% 49.9% U13 8.9% 22.2% 8.9% 51.4% 0% 20% 40% 60% 80% 100% 5 ankle sprains 2 3 ankle sprains 1 ankle sprain No ankle sprains *** P < Fig. 3 Bar chart showing the number of previous ankle sprains for U13, U14, and U15 level players (age < 13, 14, and 15 years, respectively). Black, 5 sprains; dark gray, 2 or 3 sprains; medium gray, one sprain; light gray: no sprains. *** P < n = 2722 ankles 5 ankle sprains 67.9%, OR 17.3, CI *** Junior category 2 3 ankle sprains 1 ankle sprain 47.2%, OR 7.3, CI *** 16.0%, OR 1.6, CI *** No ankle sprains 10.9%, OR 1.0 0% 20% 40% 60% 80% 100% With ankle sprains Without ankle sprains *** P < Junior youth category Fig. 4 Bar chart showing the proportion of players with (black) and without (gray) ankle sprains during junior youth category soccer for U13, U14, and U15 players (age < 13, 14, and 15 years, respectively). Data were categorized by the number of ankle sprains sustained while playing junior category soccer. From top to bottom, the number of ankle sprains: 5 sprains, 2 or 3 sprains, one sprain, no sprains. *** P < tigating amateur adult soccer players, and reported that previous ankle sprain was the only significant predictor for new acute ankle sprains. They also found that risk increased with the number of previous injuries and was highest during the first 6 months after injury. In the present study, we confirmed that these concepts could be applicable to junior players as well. Kucera et al. 12) reported that, compared to athletes with no previous ankle sprains, young players aged 9-18 years with a single previous ankle sprain had four times greater risk of recurrent ankle sprain; whereas those with 2 previous ankle sprains had eight times greater risk of an ankle sprain incident. However, the manner in which the history of ankle sprain during the JUN playing years affects the occurrence of recurrent ankle sprains during the JY playing years has not been investigated. In the present study, we assessed the relationship between the number of previous ankle sprains during JUN playing years and the occurrence of ankle sprains during JY playing years, and found a robust relationship between them. In particular, players with 5 ankle sprains during the JUN playing years had a higher association with recurrent ankle sprains during the JY playing years. However, our findings indicated that the OR was higher than those of other studies 10-12). A discrepancy between this study and earlier ones is that the latter used multivariate analysis, whereas the former did not. Despite this analysis method, our results showed that a

6 144 JPFSM : Futatsubashi G, et al. history of ankle sprain was an important predictor for new or recurrent ankle sprains in young players, particularly in the transition period from the JUN to JY soccer category. During this transition period, soccer rules, particularly the size of the ball and court as well as the number of players in a game, are drastically altered. Therefore, it is important that a prevention program for ankle sprains be established and applied during the JUN period, and that clinicians pay close attention to the number of ankle sprains their young patients experience. With regard to prevention and rehabilitation training for ankle sprains, The FIFA 11 and its revised version The FIFA 11+ provided by the Fédération Internationale de Football Association (FIFA) should be referenced. These programs include different types (e.g., quick, bounding, cutting) of strength (e.g., the plank, static or dynamic), balance (single leg), squat, and jumping exercises, all of which would be beneficial to prevent and quickly recover from an ankle sprain. Soligard et al. 20) and Lungo et al. 21) showed that the FIFA 11+ warm-up program could be effective in reducing the rate of injuries in young female football players and elite male basketball players. In addition, Mohammadi et al. 22) and Yoshida et al. 23) suggested that a proprioceptive training program using an ankle disk was an effective treatment. Moreover, to be a good soccer player, it is essential to be skillful in both legs. Therefore, from the view of skill improvement, prevention and rehabilitation programs with appropriate bilateral leg training are important for young soccer players. Although it needs to be verified in a future study, when designing a training program for junior players, the coaches and athletic trainers should consider these programs as well, to prevent ankle sprains and their recurrence. Our results indicate that a history of ankle sprain can be a risk factor for recurrent ankle sprains in young soccer players. Considering these findings, it seems crucial to establish a medical support system, such as a rehabilitation program with the cooperation of medical doctors and athletic trainers, for young soccer players, which has not been done very extensively thus far. To prevent the recurrence of ankle sprains during the JY and JUN playing years, constructing an appropriate medical support system, including athletic trainers in cooperation with medical doctors, will be vital. After the occurrence of an ankle sprain, accurate and prompt medical diagnosis and treatment, followed by the planning and implementation of appropriate rehabilitation and physical training, are crucial for quick recovery from an ankle sprain. It should be emphasized that managers and instructors are responsible for constructing such systems. In addition, continual education and consultation of players parents would play an important role in developing such systems and ensuring full recovery injuried players from not only ankle sprains, but also from other growthand development-related sports injuries. Furthermore, researchers involved with sports medicine should consis- tently follow up and update their knowledge regarding soccer and sports injuries. This study has some methodological limitations. First, there could be a latent selection bias because we selected 28 of 45 teams and obtained a questionnaire recovery rate of approximately 71%. However, to avoid undesirable biases arising from location and competition level, we carefully selected teams from 7 regions of Tokyo at random by referring to the results of competition regular-season matches of the U15 category in 2009 (e.g., regional tournaments, Tokyo finals, Kanto-Region finals, and All Japan finals). In addition, to ensure reliable statistics, only responses for questionnaires that were completed for all questions were accepted for further analyses. The final number of respondents was 1,361, which appeared to be a fairly large sample size for the statistical analyses. The region of the study was another limitation. The survey was conducted in the Tokyo area and, therefore, our findings would not be applicable to other regions or countries. In a future study, we need to perform the same survey in different regions across Japan to validate our findings. We also have to admit that the response rate was not sufficiently high. Of the 2,180 players included in this study (28 teams), 1,498 players (68.7%) completed the questionnaire, but only 1,361 players (62.4%) were ultimately included in the study. The response rate of the players with ankle sprains or symptoms of ankle sprains was possibly higher than that of players without injuries and could lead to selection bias. Although we emphasized that the players must complete the questionnaire with parental assistance, we cannot fully rule out that this rather low response rate was also a limitation. Moreover, the response rates for all the 28 teams were almost the same; thus, we believe that differences in athletic level and location should have little influence on the present results. Second, the present study was cross-sectional in nature, and therefore, we could not provide the detailed mechanisms of frequent ankle sprains during JY soccer activities. Third, we could not rule out the possibility that our findings were biased by memories of previous ankle sprains, considering that it was a retrospective cohort study. To eliminate this bias, we instructed the players to complete the questionnaire with their parents assistance. Therefore, we believe that this potential memorybased drawback was also minimized. Finally, although injuries were reported by the youth players together with their parents, the reporting accuracy could be questioned. In addition to a considerable risk of recollection bias, especially regarding experiences from 3-4 years earlier, knowledge of injury diagnostics could be lacking. Hence, it is possible that the players and their parents were not able to specify details about the severity of their ankle sprain. Therefore, a longitudinal study is needed to clarify the relationship between ankle sprain severity and subsequent risk for recurrent ankle sprain. Furthermore, we emphasize that an extensive cohort study including

7 JPFSM: Risk of recurrent ankle sprain in young soccer players 145 physiotherapists, athletic trainers, and coaches is needed. When an ankle sprain occurs during sports activities, first aid and functional assessments by an athletic trainer and an accurate diagnosis using X-ray Photography (X- P) or Magnetic Resonance Imaging (MRI) by a physician are integral during both the early and progressive stages. Furthermore, many studies have classified the categories of severity according to the time until the player was fully able to take part in all types of organized soccer play 7,11), which appears to be beneficial to clarify the relationship between the severity and recurrence of ankle sprains in a future study. In summary, this is the first study to investigate whether ankle sprains sustained during the JUN (U12) playing years could indicate an increased risk of subsequent ankle sprains during the JY (U13-15) playing years. In particular, players with 5 ankle sprains during JUN could be at higher risk of incurring recurrent ankle sprains during their JY playing years (OR, 17.3; CI, ). The results may help clinicians improve preventive checkups and establish preventive medical support for ankle sprains in JUN and JY soccer players. Future studies are needed to reconfirm the results of the present study using a crosssectional approach in conjunction with a prospective cohort study for JUN and JY players. In addition, we need to conduct a longitudinal study to determine the mechanisms of recurrent ankle sprains in young players. References 1) Emery CA, Meeuwisse WH and Hartmann SE Evaluation of risk factors for injury in adolescent soccer: implementation and validation of an injury surveillance system. Am J Sports Med 33: ) Giza E and Micheli LJ Soccer injuries. Med Sport Sci 49: ) Junge A, Chomiak J and Dvorak J Incidence of football injuries in youth players. 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