Upper Extremity Injuries in Soccer

THE ELBOW

Ekstrand and colleagues¹ reported that 10% of all upper extremity injuries in professional soccer players are elbow injuries, of which only 19% are considered severe injuries that require more than 28 days of absence from playing soccer. The most common elbow injuries in their cohort were elbow medial collateral ligament (MCL) sprain and olecranon bursitis.

Elbow MCL is the primary constraint of the elbow joint to valgus stress, and MCL sprain occurs when the elbow is subjected to a valgus, or laterally directed force, which distracts the medial side of the elbow, exceeding the tensile properties of the MCL.¹⁶ A thorough physical examination that includes valgus stress tests through the arc of elbow flexion and extension to elicit a possible subjective feeling of apprehension, instability, or localized pain is essential for optimal evaluation and treatment.^16,17 Imaging studies (X-ray and stress X-rays, dynamic ultrasound, computed tomography [CT], magnetic resonance imaging [MRI], and MR arthrography) have a role in further establishing the diagnosis and identifying possible additional associated injuries.¹⁶ The treatment plan should be specifically tailored to the individual athlete, depending on his demands and the degree of MCL injury. In soccer, which is a non-throwing shoulder sport, nonoperative treatment should be the preferred initial treatment in most cases. Ekstrand and colleagues¹ showed that this injury requires a mean of 4 days of absence from soccer for outfield players and a mean of 21 days of absence from soccer for goalkeepers, thereby indicating more severe sprains and cautious return to soccer in goalkeepers. Athletes who fail nonoperative treatment are candidates for MCL reconstruction.¹⁶

The olecranon bursa is a synovium-lined sac that facilitates gliding between the olecranon and overlying skin. Olecranon bursitis is characterized by accumulation of fluid in the bursa with or without inflammation. The fluid can be serous, sanguineous, or purulent depending on the etiology.¹⁸ In soccer, traumatic etiology is common, but infection secondary to cuts or scratches of the skin around the elbow or previous therapeutic injections around the elbow should always be ruled out. Local pain, swelling, warmth, and redness are usually the presenting symptoms. Aseptic olecranon bursitis may be managed non-surgically with ‘‘benign neglect’’ and avoidance of pressure to the area, non-steroidal anti-inflammatory drugs, needle aspiration, corticosteroid injection, compression dressings, and/or padded splinting; whereas acute septic bursitis requires needle aspiration for diagnosis, appropriate oral or intravenous antibiotics directed toward the offending organism, and, when clinically indicated, surgical evacuation/excision of the bursa.¹⁸ When treating this condition with cortisone injection, possible complications, such as skin atrophy, secondary infection, and chronic local pain, have been reported and should be considered.¹⁹

Severe elbow injuries in professional athletes in general,^20-22 and soccer players specifically, are elbow subluxations/dislocations and elbow fracture. The mechanism of injury is usually contact injury with an opponent player or a fall on the palm with the arm extended. Posterolateral is the most common type of elbow dislocation. Elbow dislocations are further classified into simple (no associated fractures) and complex (associated with fractures) categories.²² Simple dislocations are usually treated with early mobilization after closed reduction; it is associated with a low risk for re-dislocation and with generally good results. The complex type of elbow fracture dislocation is more difficult to treat, has higher complication and re-dislocation rates, and requires operative treatment in most cases compared with simple dislocation.²² The “terrible triad” of the elbow (posterior elbow dislocation, radial head fracture, and coronoid fracture) represents a specific complex elbow dislocation scenario that is difficult to manage because of conflicting aims of ensuring elbow stability while maintaining early range of motion.²²

Isolated fracture around the elbow should be treated based on known principles of fracture management: mechanism of injury, fracture patterns, fracture displacement, intra-articular involvement, soft tissue condition, and associated injuries.

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