Saturday, August 7, 2010

Flop-Roll-and-Face-itis (Marin IJ)

For the last few weeks, each dawn has awakened with the planet’s greatest team competition on television with vuvuzela horns as a brain-buzzing soundtrack.
As a fan, this World Cup has been thrilling to watch. As a physician, however, I’ve found it puzzling. Each morning, I witness an epidemic of a peculiar type of injury. Soccer players, some of the fittest of all athletes, fall to the ground after the slightest hint of contact – and proceed to roll around, hands clamped to their faces as is they’re mourning the death of a loved one. These men are stricken, horribly, for seconds to minutes at a time, and then bounce back to their feet as if nothing has happened. It’s odd actually, and I must admit that my Emergency Department (ED) experience hasn’t given me a clue as to what this mysterious soccer affliction (shall we call it “flop-roll-and-face-itis”) might be.

People with kidney stones will often rock back and forth in misery, unable to find a comfortable position. Patients with migraines frequently hold their hands to their faces, to shield their eyes from the light. Narcotic abusers may shift dramatically from a pose of comfort to one of excruciating distress when they realize they are being watched. But, in terms of traumatic injury, these soccer-induced spells are original. Take the Brazil-Portugal game, a defensive struggle that ended in a 0-0 tie. In this game, between two elite teams, there were more stricken players then quality shots on goal. For example… a Portuguese player feels a soft hand to his back and is launched onto the ground, arms splayed, emulating Dicaprio in The Titanic. His head rests on the ground for a moment and then he rolls to his back, his hands go to his face, he flexes his knees and rotates back and forth on the turf. What is hurt? Is it his head? Is it his Achilles tendon? The referee runs in with a yellow card for the Brazilian who touched him, and suddenly the Portuguese player is cured. He pops up, ready for another run on goal. Later, a Brazilian takes cleats to the heel and falls to the ground, clenching both ankles with his hands, and rolls, 1, 2, 3, 4, 5 times! What an odd injury this is! The announcer, a Brit, dryly takes note; “If you roll around a lot you are not as hurt as if you are lying still, in real pain.”

Could it be that these players are faking their injuries? I asked Dr. Joseph Centeno, an orthopedic surgeon and sports medicine specialist at Kaiser-Permanente. "Let's put it this way,” he replied, “I've never had to operate on a flopper." Next, I talked to my brother, Chris Ballard, a writer for Sports Illustrated who covers the NBA. Had he ever seen this type of injury in the sport of basketball? “Only on rare occasions,” he said, “and strangely enough it seems to only afflict European or South American players such as Vlade Divac or Manu Ginobili.”

But, all ridiculous theater aside, I should note that serious injuries do occur in the game of soccer. Many stars, including Ballack of Germany, Essien of Ghana, and Beckham of England, are sitting out the World Cup with physical ailments. And here in the U.S., as soccer gains greater popularity as a youth sport, thousands of kids are suffering knee, ankle, face, and head injuries. Each year, approximately 75,000 children ages five to 14 are treated in EDs for soccer-related injuries – more than the number of visits due to gymnastics, ice hockey and skiing injuries combined. Of these, many are knee injuries, particularly anterior cruciate ligament (ACL) tears. The ACL tear is a serious impairment that usually requires surgery and extended rehab, so it is worth taking note that the risk of this injury can be minimized by reducing the yearly load of play (in other words, taking some time off) and employing structured warm-up before play.

Of greater concern, however, are soccer-related head injuries – as even minor ones can have cumulative consequences. Head trauma, of course, is a problem in many sports, but soccer players are exposed in a rather unique manner because they are trained to repeatedly strike a rapidly moving ball with their unhelmeted craniums. A Canadian study, recently published in the journal Injury, found that 15% of soccer-related ED visits were for head injuries, of which 11% (of these) were concussions. Another Canadian study found that a disturbingly high number of youngsters (age 12-17) playing team soccer had evidence of concussion (over 50%) and that this percentage was significantly lower in those wearing protective headgear. A third study, published in the journal Neurosurgery, found decreased neuropsychological scores and reaction times in professional soccer players who had suffered a head injury the day before – even when these players claimed they did not feel any ill effects.

So, does any of this help explain the puzzling frequency of dramatic injuries at this year’s World Cup? I think it does. Some of these players, it seems, are damaged by years of forceful headers and contested corners. And thus, they have developed the deluded judgment that turf flopping is an acceptable strategic play (and one that the referee and the public won’t notice). From a purely clinical standpoint, they are wrong. The intent of flop-roll-and-face-itis may be difficult for a referee to recognize in real time, but with a remote control and a little clinical perspective, it’s a remarkably easy diagnosis.