Injuries in Adolescent Footballers:

Young athletes are susceptible to many of the same injuries as their adult counterparts. However there are some significant differences in the types of injuries sustained by children and adolescents because of differences in the structure of growing bones compared to adult bone.

The main differences between adult and growing bone are:

  • The articular cartilage is a thicker layer than in adult bone and can remodel.
  • The junction between the epiphyseal plate and metaphysis is vulnerable to disruption, especially from shearing forces.
  • Tendon attachment sites (apophyses) are cartilaginous plates that provide a relatively weak cartilaginous attatchment, predisposing to avulsion injuries.
  • The metaphysis of long bones in children is more resilient and elastic, withstanding greater deflection without fracture.
  • During rapid growth phases, bone lengthens before muscles and tendons are able to stretch correspondingly this can lead to muscle and tendon injuries, and can also be responsible for a growing athlete losing coordination and therefore reducing their performance.

As a result children are more susceptible number of acute and overuse injuries often affecting the growth plates, apohyses and joint surfaces.

Acute Injuries:

-Contusions                 -Sprains

– Strains                       -Dislocations


Overuse Injuries:

-Overuse injuries are chronic injuries related to repetitive stress on the musculoskeletal system without sufficient recovery time.

-Often seen with a rapid increase in training and in athletes training at consistently high levels.

Predisposing factors:

  • Hard training surfaces
  • Inappropriate equipment
  • Coaching.
  • BMI
  • Age
  • Decreased flexibility and extremity malalignment
  • Foot hyper pronation,
  • Excessive ligament laxity
  • Muscle weakness or imbalance.

Typical presentation:

  • Insidious onset no acute injury.

Important considerations:

  • location of the pain
  • Surface training on
  • Type of sport being played
  • Intensity, duration and frequency of participation.
  • Recent increase in the training/


  • Relative rest ↓ intensity or frequency of play
  • Reduce inflammation
  • Regain strength
  • Restore range of motion.

Overuse injuries commonly seen in youth footballers include; stress fractures, chronic groin pain, apohysitis such as Osgood Schlatters and Severs disease, tensonoses and patellofemoral pain syndrome.

Stress Fractures:

-They result from repetitive, excessive loading of bone. Bone normally undergoes remodelling in response to stress. A stress fracture occurs when there is an imbalance between bone resorption and formation leading to microfractures that may progress into stress fractures.

-Gradual onset of pain during or immediately after exercise, and over time progresses to having pain with non-sport activities.

-Often following a change in the training program


  • Localised tenderness over the involved bone.
  • Clinical diagnosis confirmed radiologically.
  • Plain radiographs have a high specificity but low sensitivity for picking up stress fractures.
  • Stress fractures usually appear normal for the first 2 to 3 weeks of symptoms
  • Radionuclide bone scan used to diagnose stress fractures, with a high sensitivity for showing focal uptake at the fracture site.

Fig. 9   Calcaneal stress
fractures. (A) Sagittal
proton density image
through the calcaneus
shows a faint fracture
line with adjacent low-
signal marrow edema.


  • Avoidance of painful activities until healing occurs.
  • Tibial and metatarsal stress fractures this includes complete rest for 1 month,

#cross training with deep water running in the pool or stationary bike is allowed.

  • Gradual return to sport, ↑ impact activities by 10% per week over an 8 week period.
  • No hard surface running
  • More cushioned running shoe

Chronic Groin Pain:

-common injuries in footballers; due to the forces they endure with kicking activities.

-Important as physiotherapists that we accurately assess and treat these injuries before they develop into longstanding debilitating injuries.

-A number of potential sites that can be causing groin pain., these include:

  • adductor tendons
  • hip flexors
  • pubic symphysis
  • lumbar spine + SIJ stiffness
  • Inguinal wall weakness.

Typical Presentation:

  • Insidious onset of groin pain in adductor tendons.
  • Over time can spread to other regions and become bilateral.
  • Pain is aggravated by exercise with running, twisting/turning and kicking the most challenging activities.
  • Often notice a ↓ in sporting performance.
  • Pain following activity and is often accompanied by stiffness, particularly the next morning.
  • Progressive deterioration until symptoms prevent sports participation.


  1. Observation:
    1. Standing
    2. Walking
    3. Supine
    4. Active movements
      1. Hip flex/ext
      2. Hip abd/add
      3. Hip IR/ER
      4. Lumbar spine movements
      5. Abdominal flexion
      6. Passive movements:
        1. Hip quadrant: flexion, adduction, internal rotation
        2. Internal rotation then with added adduction
        3. Adductor muscle stretch
        4. Quads stretch
        5. Illiopsoas stretch (Thomas Test)
        6. Resisted movements
          1. Hip flex (Thomas position)
          2. Hip flex in adduction
          3. Hip adduction
          4. Squeeze test
          5. Adduction/abduction
          6. Abdominal flexion
          7. Palpation:
            1. Adductor muscle tendons:
            2. Pubic symphysis/ramus
            3. Rectus abdominis
            4. Illiopsoas
            5. Special tests:
              1. Pelvic symmetry
              2. Lumbar spine
              3. SIJ
              4. Thomas position with added neural tension
              5. FABER test
              6. Trendelenberg test

N.B. Crossover Sign: if a patients typical groin pain is reproduced when one of the provocation tests is performed on the contralateral side. A positive cross over sign suggests substantial functional impairment.

Most patients with groin pain continue to train and play until it gets to the point where the pain prevents them from running. When the condition has reached that stage, a lengthy period of rest and rehabilitation is usually required. It is therefore imperative that we act on early warning signs and implement appropriate measures to prevent injury progression.

Clinical warning signs:

  • tightness/stiffness during or after activity with minimal relief from stretching
  • loss of acceleration
  • Loss of maximal sprinting speed
  • loss of distance with long kick or run
  • vague discomfort with deceleration



Rest + active rehabilitation exercises. There are 5 key principles for treatment:

  1. Exercise performed pain free
  2. Indentify and reduce the source of increased load
  3. Improve lumbopelvic stability
  4. Strengthen local musculature
  5. Progress the patients level of activity on the basis of regular clinical assessment rather than specific time frame.

i.      Return to running when

  1. Brisk walk pain free
  2. Resisted hip flexion in Thomas position pain free
  3. No crossover sign
  4. Minimal adductor guarding

-Return to sport:

–          Six to eight 100 m run throughs with 10 m acceleration and deceleration phases with walk recover, reassess squeeze test after each session

–          Lateral running can be commenced once above running is completed and athlete remains pain free with reassessment


  • Refer tosports physician
  • X rays and/or MRI


-Chronic traction of a tendon at its insertion, resulting in a microavulsion at the bone cartilage junction.

-Quite common during periods of rapid growth.

-Apophysitis is a self limiting condition with symptom resolution occurring with the fusion of the secondary ossification centres.


  • activity modification
  • direct icing following games
  • short term NSAIDs
  • Physiotherapy to improve flexibility and strength.

Osgood Schlatters:

-Traction apohysisits that occurs at the growth plate of the tibial tuberosity. Repeated contractions of the quadriceps muscle may cause softening and partial avulsion of the secondary ossification centres.

-Extremely common in adolescents aged between 11 and 15 at the time of a big growth spurt.

-Associated with a high level of physical activity, especially sports involving running and jumping.


  • soft tissue swelling and localised tenderness over the tibial tuberosity.
  • Associated tightness of surrounding muscles
  • pain with passive knee flexion or isometric extension.


  • Self limiting and will settle with time, can take up to two years.
  • Activity modification
  • Relative rest is an essential aspect of treatment.
  • Pain should be the guide as to the limitation in activity.
  • Local icing following games
  • Lower limb stretching program.

Sinding-Larsen Johansson Lesion:

Similar to Osgood Schlatters except it affects the inferior pole of the patella at the superior attachment of the patella tendon. Not as common as Osgood Schlatters but the same treatment principles apply.

Severs Disease:

-Traction apophysitis of the insertion of the Achilles tendon to the calcaneus

-Typically occurs between the ages of 7 and 10 years.

-More common in boys and occurs bilaterally in 60% of cases.

– common following a period of rapid growth during which muscles and tendons become tighter as the bones become longer.


  • Activity related pain
  • Localised tenderness plus swelling around at the site of insertion of the Achilles tendon.
  • Tightness of the gastrocnemius and soleus muscles


  • activity modification so that the child becomes pain free.
  • Advise that condition will settle within six to twelve months
  • Heel raises can provide some relief
  • Physio to reduce local swelling
  • Exercise program focusing on stretching and strengthening the calf muscles.


Tendonitis is much less common in a young athlete population, because the apophysis (the site of attachment of the tendon to the bone) is weaker than the tendon itself and more likely to suffer an injury.

Patellofemoral Pain Syndrome:

-Common injuries affecting the female adolescent athlete population.

-Insidious onset knee pain, not associated with an acute injury or instability.

-Pain is exacerbated by:

  • Jumping
  • Climbing stairs
  • Sitting for long periods of time.

Associated Findings:

  • patellofemoral joint overload
  • quadriceps weakness
  •  tight quadriceps and hamstring muscles
  •  abnormal patella tracking secondary to VMO weakness

-Knee examination is normal with mild pain with patella compression.


  • VMO strengthening,
  • Lateral soft tissue release
  • Lower limb stretches
  • patella mobilisations.
  • orthotic prescription patients excessive foot pronation


HOW MUCH IS TOO MUCH: Overtraining:

-When treating any athlete it is important that you get a detailed history of the individual’s frequency, duration and intensity of both training and competition.

-Due to the musculoskeletal differences in the growing athlete it is important that children do not overtrain, otherwise they increase the susceptibility to a number of the above mentioned overuse injuries.

General Guideline:

–          Training frequency up to 14 years should not exceed 3 times per week, over 15 may train/play up to 5 times per week.

–          The duration of each session should not exceed 1.5 hours, including a warm up and stretching component

–          Training sessions should be varied to work on different aspects of the game, whilst reducing the stress on one area of the body.

–          Should avoid training on hard surfaces to reduce the impact on the growing body.