The Open Sports Sciences Journal




ISSN: 1875-399X ― Volume 14, 2021
RESEARCH ARTICLE

Prevalence and Risk Factors of Ankle Sprain Among Male Soccer Players in Tabuk, Saudi Arabia: A Cross-Sectional Study



Hamad S. Al Amer1, *, Shahul Hameed Pakkir Mohamed1
1 Department of Physical Therapy, Faculty of Applied Medical Sciences, University of Tabuk, Tabuk 71491, Saudi Arabia

Abstract

Background:

Ankle sprains are common among soccer players, and their risk factors are well documented in the literature. In Saudi Arabia, some healthcare and sport-related characteristics provide the necessity for investigating the prevalence and risk factors of ankle sprain in that region as well.

Objective:

To analyze the prevalence of lower limb injuries and risk factors of ankle sprains among male soccer players in Tabuk, Saudi Arabia.

Methods:

A cross-sectional study among 400 male soccer players from different sports clubs in Tabuk, Saudi Arabia was conducted. A self-structured questionnaire was used to collect data related to ankle sprains. Chi-square, Fisher’s exact tests, and unpaired t-tests were used to test the association between variables. Univariate logistic regression analysis was used to identify the risk factors.

Results:

Ankle sprains were the most prevalent, reported by 63.8%. Previous ankle injury, lack of stretching, lack of warm-up, and not wearing bracing were identified as significant risk factors. A total of 47.9% of players preferred to go to the hospital for treatment, 15.8% selected physical therapy, while 56% had no prior education regarding injury prevention.

Conclusion:

Ankle sprain is the most prevalent lower limb injury. Risk factors include previous ankle injuries, lack of stretching, lack of warm-up, and not wearing bracing. Players have little knowledge of physical therapy measures and lack of injury prevention education. Our findings suggest that increasing the awareness of injuries and proper physical therapy measures might assist in preventing recurrence of ankle sprains among male soccer players.

Keywords: Ankle sprain, Prevalence, Risk Factors, Soccer, Physical Therapy, Saudi Arabia.


Article Information


Identifiers and Pagination:

Year: 2020
Volume: 13
First Page: 27
Last Page: 33
Publisher Id: TOSSJ-13-27
DOI: 10.2174/1875399X02013010027

Article History:

Received Date: 25/12/2019
Revision Received Date: 05/02/2020
Acceptance Date: 12/02/2020
Electronic publication date: 23/05/2020
Collection year: 2020

© 2020 Al Amer and Mohamed

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Department of Physical Therapy, Faculty of Applied Medical Sciences, University of Tabuk, Tabuk 71491, Saudi Arabia; Tel: +966144562777; Fax: +966144222202; E-mail halamer@ut.edu.sa





1. INTRODUCTION

Soccer (or football) is the most popular sport in Saudi Arabia [1Sadat-Ali M, Sankaran-Kutty M. Soccer injuries in Saudi Arabia. Am J Sports Med 1987; 15(5): 500-2.
[http://dx.doi.org/10.1177/036354658701500513] [PMID: 3674274]
]. Ankle sprain is the most common lower limb injury experienced by individuals involved in physical activity, comprising approximately 80% of ankle injuries [2Fong DT, Hong Y, Chan LK, Yung PS, Chan KM. A systematic review on ankle injury and ankle sprain in sports. Sports Med 2007; 37(1): 73-94.
[http://dx.doi.org/10.2165/00007256-200737010-00006] [PMID: 17190537]
, 3Woods C, Hawkins R, Hulse M, Hodson A. The Football Association Medical Research Programme: An audit of injuries in professional football: An analysis of ankle sprains. Br J Sports Med 2003; 37(3): 233-8.
[http://dx.doi.org/10.1136/bjsm.37.3.233] [PMID: 12782548]
]. Ankle sprain injuries usually occur during landing on irregular surfaces, such as the foot of another player, or incorrect foot positioning at landing, resulting from delayed reaction time of the peroneal muscles or a tackle from the medial side [4Kofotolis ND, Kellis E, Vlachopoulos SP. Ankle sprain injuries and risk factors in amateur soccer players during a 2-year period. Am J Sports Med 2007; 35(3): 458-66.
[http://dx.doi.org/10.1177/0363546506294857] [PMID: 17218660]
, 5Fong DT, Chan YY, Mok KM, Yung PS, Chan KM. Understanding acute ankle ligamentous sprain injury in sports. Sports Med Arthrosc Rehabil Ther Technol 2009; 30;1:14
[http://dx.doi.org/10.1186/1758-2555-1-14]
]. Recurrent ankle sprains account for approximately 16% of all ankle sprains [6Swenson DM, Collins CL, Fields SK, Comstock RD. Epidemiology of U.S. high school sports-related ligamentous ankle injuries, 2005/06-2010/11. Clin J Sport Med 2013; 23(3): 190-6.
[http://dx.doi.org/10.1097/JSM.0b013e31827d21fe] [PMID: 23328403]
]. Studies have reported that the ankle reinjury rate in soccer is between 4% and 29% [7Cloke DJ, Spencer S, Hodson A, Deehan D. The epidemiology of ankle injuries occurring in English Football Association academies. Br J Sports Med 2009; 43(14): 1119-25.
[http://dx.doi.org/10.1136/bjsm.2008.052050] [PMID: 19106152]
-9Waldén M, Hägglund M, Ekstrand J. Time-trends and circumstances surrounding ankle injuries in men’s professional football: An 11-year follow-up of the UEFA Champions League injury study. Br J Sports Med 2013; 47(12): 748-53.
[http://dx.doi.org/10.1136/bjsports-2013-092223] [PMID: 23813486]
]. One recent study from Saudi Arabia reported ankle injuries (n = 399) in physical education and sports among Saudi high school male students in Riyadh. The authors found that the range of prevalence of ankle injuries was 14%-34.7% [10Almalki MA, Alowaime NA, Alanazi AM, et al. Prevalence of ankle injuries in physical education and sports classes among saudi high school male students in Riyadh, Saudi Arabia. J Musculoskelet Surg Res 2018; 2: 16-20.
[http://dx.doi.org/10.4103/jmsr.jmsr_24_17]
].

Several studies found that soccer injury rates varied depending on competition level, age, and gender [11Söderman K, Alfredson H, Pietilä T, Werner S. Risk factors for leg injuries in female soccer players: A prospective investigation during one out-door season. Knee Surg Sports Traumatol Arthrosc 2001; 9(5): 313-21.
[http://dx.doi.org/10.1007/s001670100228] [PMID: 11685365]
-13Tegnander A, Olsen OE, Moholdt TT, Engebretsen L, Bahr R. Injuries in Norwegian female elite soccer: A prospective one-season cohort study. Knee Surg Sports Traumatol Arthrosc 2008; 16(2): 194-8.
[http://dx.doi.org/10.1007/s00167-007-0403-z] [PMID: 17899007]
]. During the 2010 FIFA World Cup competition, ankle sprain was the most prevalent condition, and approximately 50% of players were prevented from participating in the competition [14Dvorak J, Junge A, Derman W, Schwellnus M. Injuries and illnesses of football players during the 2010 FIFA World Cup. Br J Sports Med 2011; 45(8): 626-30.
[http://dx.doi.org/10.1136/bjsm.2010.079905] [PMID: 21257668]
]. The recognition of risk factors leading to ankle sprain appears to be the keystone for effective ankle sprain injury prevention strategies [15Zech A, Wellmann K. Perceptions of football players regarding injury risk factors and prevention strategies. PLoS One 2017; 12(5)e0176829
[http://dx.doi.org/10.1371/journal.pone.0176829] [PMID: 28459845]
]. Two types of risk factors are suggested: extrinsic and intrinsic risk factors. Extrinsic risk factors include the total amount of training and number of played games, climatic factors, pitch surface, playing field status, equipment, and rough play. Intrinsic risk factors include joint flexibility, instability, preceding injuries, and inadequate rehabilitation [16Inklaar H. Soccer injuries. II: Aetiology and prevention. Sports Med 1994; 18(2): 81-93.
[http://dx.doi.org/10.2165/00007256-199418020-00002] [PMID: 9132922]
-18Dvorak J, Junge A. Football injuries and physical symptoms. A review of the literature. Am J Sports Med 2000; 28(5)(Suppl.): S3-9.
[http://dx.doi.org/10.1177/28.suppl_5.s-3] [PMID: 11032101]
].

Previous studies reported that players with histories of ankle sprain, players wearing air-filled heel shoes, and players who did not stretch the ankle joint structure before exercising were 4.9, 4.3, and 2.6 times more likely to withstand an ankle sprain [19McKay GD, Goldie PA, Payne WR, Oakes BW. Ankle injuries in basketball: Injury rate and risk factors. Br J Sports Med 2001; 35(2): 103-8.
[http://dx.doi.org/10.1136/bjsm.35.2.103] [PMID: 11273971]
]. Limited dorsiflexion movement in the ankle [20de Noronha M, Refshauge KM, Herbert RD, Kilbreath SL, Hertel J. Do voluntary strength, proprioception, range of motion, or postural sway predict occurrence of lateral ankle sprain? Br J Sports Med 2006; 40(10): 824-8.
[http://dx.doi.org/10.1136/bjsm.2006.029645] [PMID: 16920769]
], the usage of artificial turf ground while playing soccer [21Orchard JW, Powell JW. Risk of knee and ankle sprains under various weather conditions in American football. Med Sci Sports Exerc 2003; 35(7): 1118-23.
[http://dx.doi.org/10.1249/01.MSS.0000074563.61975.9B] [PMID: 12840631]
], and posteriorly-positioned fibula [22Eren OT, Kucukkaya M, Kabukcuoglu Y, Kuzgun U. The role of a posteriorly positioned fibula in ankle sprain. Am J Sports Med 2003; 31(6): 995-8.
[http://dx.doi.org/10.1177/03635465030310064101] [PMID: 14623669]
] were also reported as risk factors for ankle sprains.

Previous ankle injury is one of the most common risk factors for acute ankle injuries; therefore, it is very important to recognize strategies for preventing first-time occurrence of acute ankle injuries [23van Rijn RM, van Os AG, Bernsen RMD, Luijsterburg PA, Koes BW, Bierma-Zeinstra SMA. What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med 2008; 121(4): 324-331.e6.
[http://dx.doi.org/10.1016/j.amjmed.2007.11.018] [PMID: 18374692]
, 24Yeung MS, Chan KM, So CH, Yuan WY. An epidemiological survey on ankle sprain. Br J Sports Med 1994; 28(2): 112-6.
[http://dx.doi.org/10.1136/bjsm.28.2.112] [PMID: 7921910]
]. In order to prevent acute ankle injuries, some players use ankle braces during sports activities. A few systematic reviews reported that ankle bracing was effective in reducing the re-occurrence of ankle sprain among athletes [25Handoll HH, Rowe BH, Quinn KM, de Bie R. Interventions for preventing ankle ligament injuries. Cochrane Database Syst Rev 2001; 3(3)CD000018
[PMID: 11686947]
, 26Dizon JMR, Reyes JJB. A systematic review on the effectiveness of external ankle supports in the prevention of inversion ankle sprains among elite and recreational players. J Sci Med Sport 2010; 13(3): 309-17.
[http://dx.doi.org/10.1016/j.jsams.2009.05.002] [PMID: 19586798]
]. The benefits of taping, neuromuscular exercising, and bracing for preventing injuries during team sports have been emphasized in the literature [27Verhagen EA, Bay K. Optimising ankle sprain prevention: A critical review and practical appraisal of the literature. Br J Sports Med 2010; 44(15): 1082-8.
[http://dx.doi.org/10.1136/bjsm.2010.076406] [PMID: 21047837]
, 28Hübscher M, Zech A, Pfeifer K, Hänsel F, Vogt L, Banzer W. Neuromuscular training for sports injury prevention: A systematic review. Med Sci Sports Exerc 2010; 42(3): 413-21.
[http://dx.doi.org/10.1249/MSS.0b013e3181b88d37] [PMID: 19952811]
]. Appropriate warm-up and stretching exercises are the most commonly recommended measures for the prevention of acute sports injuries [29Hedrick A. Physiological responses to warm-up. Natl Strength Cond Assoc J 1992; 14(5): 25-7.
[http://dx.doi.org/10.1519/0744-0049(1992)014<0025:PRTWU>2.3.CO;2]
, 30Ekstrand J, Gillquist J, Möller M, Oberg B, Liljedahl SO. Incidence of soccer injuries and their relation to training and team success. Am J Sports Med 1983; 11(2): 63-7.
[http://dx.doi.org/10.1177/036354658301100203] [PMID: 6846683]
]. A few studies suggested performing warm-up exercises prior to sports activity to reduce the risk of injury [31Bixler B, Jones RL. High-school football injuries: Effects of a post-halftime warm-up and stretching routine. Fam Pract Res J 1992; 12(2): 131-9.
[PMID: 1621533]
-33Olsen OE, Myklebust G, Engebretsen L, Holme I, Bahr R. Exercises to prevent lower limb injuries in youth sports: Cluster randomised controlled trial. BMJ 2005; 330(7489): 449-52.
[http://dx.doi.org/10.1136/bmj.38330.632801.8F] [PMID: 15699058]
].

Based on the theoretical framework for injury prevention, effective actions should be directed towards the adjustment of the player’s attitude and behaviors regarding risk factors and prophylactic measures [34Van Tiggelen D, Wickes S, Stevens V, Roosen P, Witvrouw E. Effective prevention of sports injuries: A model integrating efficacy, efficiency, compliance and risk-taking behaviour. Br J Sports Med 2008; 42(8): 648-52.
[http://dx.doi.org/10.1136/bjsm.2008.046441] [PMID: 18400875]
, 35Lund JALE. Accident prevention. Presentation of a model placing emphasis on human, structural and cultural factors. Saf Sci 2004; 42: 271-324.
[http://dx.doi.org/10.1016/S0925-7535(03)00045-6]
]. Because of the rate of recurrence and debilitating nature of these injuries, it is critical for coaches or trainers, physical therapists, and physicians to identify leading risk factors for ankle injury. This would assist in the application of preventive measures and, in turn, would reduce the likelihood of injury occurrence and recurrence.

Tabuk region is located in the northwest part of Saudi Arabia. The Jordanian border bounds it from the north and the red sea from the west. It is known by its colder climate in comparison to other regions of Saudi Arabia. In terms of sport, Tabuk has four professional soccer clubs and one stadium that hosts local soccer competitions. There are also a number of public and private soccer fields, turfed and non-turfed, scattered all over the region. Presently, sport-related healthcare professionals are relatively less in number in the Tabuk region, and there are no specialized clinics or hospitals for athletic or sports injuries. The only available options of treatment in Tabuk for injured athletes are general medical facilities. All these healthcare and sport-related factors provide the necessity for investigating the prevalence and risk factors of ankle sprain in Tabuk region, and how these data may differ from what was reported in the literature. To date, there are insufficient studies of ankle sprain injuries among soccer players in Tabuk and other regions in Saudi Arabia. In this study, therefore, we analyzed the prevalence of lower limb injuries and risk factors of ankle sprain among male soccer players in Tabuk, Saudi Arabia. It was hypothesized that, in male soccer players, there will be a high prevalence rate of ankle sprain among the lower limb injuries. We also hypothesized that there will be significant demographic and play-related risk factors correlated with ankle sprain rates.

2. MATERIALS AND METHODS

2.1. Participants

This cross-sectional study was conducted from February to August 2018. A total of 400 male soccer players, professionals and amateurs, from four sport clubs in Tabuk, Saudi Arabia were recruited using a convenience sampling method. This sampling method was utilized due to the limited number of sports clubs and difficulties to access the soccer players at any time. The sample size was determined using the prevalence and risk factors of ankle sprain among the soccer players in the study population. This was calculated using a power of 80% and α = 0.05 to detect a difference of 20%. Accordingly, a total sample size of at least 400 was determined. The inclusion criteria were as follows: current soccer players (professional or amateur); between 18 and 40 years of age; and male gender (because this game is uncommon among females in Saudi Arabia). The exclusion criteria were as follows: any underlying inflammatory symptoms (e.g., redness, swelling, pain, limited range of motion) assessed through taking a full history, and any ankle or foot congenital diseases or abnormalities.

2.2. Questionnaire

A self-structured questionnaire that was based on previous research [15Zech A, Wellmann K. Perceptions of football players regarding injury risk factors and prevention strategies. PLoS One 2017; 12(5)e0176829
[http://dx.doi.org/10.1371/journal.pone.0176829] [PMID: 28459845]
] was used in this study. The questionnaire collects data relating to (1) basic demographics such as age, marital status, educational level, height, weight and body mass index (BMI); (2) occurrence and recurrence of ankle sprain among other lower extremity regions; and (3) potential risk factors, including play field-related characteristics, play environment, recurrence of injury, previous ankle injury and type of management taken, knowledge of physical therapy, received physical therapy treatment and education. The questionnaire is distributed among the participants and collected by the researchers on the same day, with the researchers presented all the time to answer any questions regarding the questionnaire. The items of the questionnaire were presented in a language appropriate for players. It was pilot-tested in a group of 10 players. The players faced no major difficulties and they could understand the questions and the response options.

2.3. Data Analysis

All categorical data are expressed as the frequency with percentage; continuous data are expressed as mean with standard deviation. Significance and associations between the dependent and independent variables were tested using Chi-square tests, Fisher’s exact tests, and unpaired t-tests. All significant variables from the Chi-square analysis were tested further using a univariate logistic regression model. The goodness of fit of the univariate logistic regression model was 0.789. All analyses were performed using SPSS 21.0 version. p-values less than 0.05 were considered significant.

3. RESULTS

A total of 400 participants with a mean age of 23.2 ± 5.9 years participated in the study. The characteristics of the participants are shown in Table 1. As illustrated in Fig. (1), ankle injury (63.8%) represented the highest percentage of complaints among all lower limb injuries. A total of 47% of the players reported injury of the right ankle, 24% of the left, and 29% in both. For those with ankle sprains in the previous year, about 42% suffered the sprain more than once, while the rest had it only one time. None of the demographic variables (age, BMI, duration of playing soccer, etc.) were significantly associated with the frequency of ankle sprain (one and more than one time) on Chi-square or Fisher exact or unpaired t-test (Table 2). The Chi-square or Fisher exact test and univariate logistic regression analysis revealed that previous ankle injury, lack of stretching, lack of warm-up and not wearing bracing were significant risk factors for ankle sprain incidence regardless of injury frequency (Tables 3 and 4). The remaining risk factors were not found to be significant (Tables 3 and 4). Of those with ankle sprains, 47.9% preferred to go to the hospital for treatment, while 33.2%, 15.8% and 3.1% chose to rest, undergo physical therapy, and other treatments, respectively. A total of 56% of players had no prior educational background regarding injury prevention.

Fig. (1)
Percentage of lower limb injuries. Ant: anterior; Post: posterior.


4. DISCUSSION

This study was conducted to evaluate the prevalence and risk factors of ankle sprain among male soccer players in the Tabuk region, Saudi Arabia. We hypothesized that there will be a high prevalence rate of ankle sprain among the lower limb injuries. We also hypothesized that there will be significant demographic and play-related risk factors correlated with ankle sprain rates. The results of this study partially support our proposed hypotheses in that ankle sprain was the most prevalent, reported by 255 of 400 participants (63.8%), with 58% and 42% reporting ankle sprain once and more than once within the prior 12 months, respectively. Some risk factors were found to be significant in our study, including previous ankle injury, lack of stretching, lack of warm-up, and not wearing bracing. However, none of the examined demographic factors was found to be significantly correlated with ankle sprain incidences.

Several authors found previous ankle injury as a significant risk factor for the recurrent ankle sprain. One group reported that 60% of the ankle sprains occurred in players with a history of previous ankle sprains [4Kofotolis ND, Kellis E, Vlachopoulos SP. Ankle sprain injuries and risk factors in amateur soccer players during a 2-year period. Am J Sports Med 2007; 35(3): 458-66.
[http://dx.doi.org/10.1177/0363546506294857] [PMID: 17218660]
]. In another study, 9 of 13 ankle sprains (69%) were associated with a history of previous ankle sprains [36Arnason A, Gudmundsson A, Dahl HA, Jóhannsson E. Soccer injuries in Iceland. Scand J Med Sci Sports 1996; 6(1): 40-5.
[http://dx.doi.org/10.1111/j.1600-0838.1996.tb00069.x] [PMID: 8680943]
]. Soccer players having a previous history of ankle sprain injury were 4.9 times more likely to sustain a recurrent ankle sprain injury than players without previous ankle sprain injury [5Fong DT, Chan YY, Mok KM, Yung PS, Chan KM. Understanding acute ankle ligamentous sprain injury in sports. Sports Med Arthrosc Rehabil Ther Technol 2009; 30;1:14
[http://dx.doi.org/10.1186/1758-2555-1-14]
]. Tropp et al. [37Tropp H, Ekstrand J, Gillquist J. Stabilometry in functional instability of the ankle and its value in predicting injury. Med Sci Sports Exerc 1984; 16(1): 64-6.
[http://dx.doi.org/10.1249/00005768-198401000-00013] [PMID: 6708781]
] also reported that players with a history of ankle injury are at a higher risk of future injury than players with no previous injury. These findings are consistent with those of the present study.

Most of the players acknowledged using regular stretching exercises for injury prevention; stretching exercises are commonly used for warm-up or cool-down routines [38Ebben WP, Hintz MJ, Simenz CJ. Strength and conditioning practices of Major League Baseball strength and conditioning coaches. J Strength Cond Res 2005; 19(3): 538-46.
[PMID: 16095401]
] and are useful to increase muscle extensibility [39Morse CI, Degens H, Seynnes OR, Maganaris CN, Jones DA. The acute effect of stretching on the passive stiffness of the human gastrocnemius muscle tendon unit. J Physiol 2008; 586(1): 97-106.
[http://dx.doi.org/10.1113/jphysiol.2007.140434] [PMID: 17884924]
-41Nakamura M, Ikezoe T, Takeno Y, Ichihashi N. Time course of changes in passive properties of the gastrocnemius muscle-tendon unit during 5 min of static stretching. Man Ther 2013; 18(3): 211-5.
[http://dx.doi.org/10.1016/j.math.2012.09.010] [PMID: 23294911]
] and for prevention of sport-related injuries. Kaini et al. [42Kiani A, Hellquist E, Ahlqvist K, Gedeborg R, Michaëlsson K, Byberg L. Prevention of soccer-related knee injuries in teenaged girls. Arch Intern Med 2010; 170(1): 43-9.
[http://dx.doi.org/10.1001/archinternmed.2009.289] [PMID: 20065198]
] reported that sports-specific warm-up, including dynamic stretching, could prevent injuries. In another study, it was reported that stretching exercises of certain muscles and joints for certain activities may enhance the effectiveness of these pre-exercise activities [43Worrell TW, Perrin DH. Hamstring muscle injury: The influence of strength, flexibility, warm-up, and fatigue. J Orthop Sports Phys Ther 1992; 16(1): 12-8.
[http://dx.doi.org/10.2519/jospt.1992.16.1.12] [PMID: 18796769]
]. The results of these studies are consistent with those of the present study in that players who perform stretching exercises before playing have a lower risk of ankle sprain.

Warm-up exercises play an important role in the prevention of ankle sprains and their effects are well known. Warm-up is one of the most commonly suggested countermeasures for sports injury [29Hedrick A. Physiological responses to warm-up. Natl Strength Cond Assoc J 1992; 14(5): 25-7.
[http://dx.doi.org/10.1519/0744-0049(1992)014<0025:PRTWU>2.3.CO;2]
]. Warm-up, together with stretching exercises, enhances the flexibility of the lower extremity joints, including the ankle [44Hubley CL, Kozey JW, Stanish WD. The effects of static stretching exercises and stationary cycling on range of motion at the hip joint. J Orthop Sports Phys Ther 1984; 6(2): 104-9.
[http://dx.doi.org/10.2519/jospt.1984.6.2.104] [PMID: 18806373]
, 45Wiktorsson-Möller M, Oberg B, Ekstrand J, Gillquist J. Effects of warming up, massage, and stretching on range of motion and muscle strength in the lower extremity. Am J Sports Med 1983; 11(4): 249-52.
[http://dx.doi.org/10.1177/036354658301100412] [PMID: 6614296]
]. The combination of warm-up, strength, and balance training with stretching had significant effects on the prevention of knee and ankle injuries [46Ekstrand J, Gillquist J, Liljedahl SO. Prevention of soccer injuries. Supervision by doctor and physiotherapist. Am J Sports Med 1983; 11(3): 116-20.
[http://dx.doi.org/10.1177/036354658301100302] [PMID: 6346912]
-48Wedderkopp N, Kaltoft M, Lundgaard B, Rosendahl M, Froberg K. Prevention of injuries in young female players in European team handball. A prospective intervention studies. Scand J Med Sci Sports 2003; 13: 371-5.
[http://dx.doi.org/10.1046/j.1600-0838.2003.00336.x] [PMID: 14617058]
]. These findings are strongly supportive of our results to the effect that a greater number of players developed ankle injury because of the poor performance of warm-up exercises.

In our study, we observed that not wearing bracing was a significant risk factor for ankle sprain. Ankle braces have been commonly used in sports to manage and prevent ankle sprains. One study reported a 69% reduction in ankle sprains in previously-injured athletes by using ankle braces [26Dizon JMR, Reyes JJB. A systematic review on the effectiveness of external ankle supports in the prevention of inversion ankle sprains among elite and recreational players. J Sci Med Sport 2010; 13(3): 309-17.
[http://dx.doi.org/10.1016/j.jsams.2009.05.002] [PMID: 19586798]
]. Studies reported the use of ankle braces for the prevention of ankle sprains among active and healthy subjects [49Papadopoulos ES, Nicolopoulos C, Anderson eg, Curran M, Athanasopoulos S. The role of ankle bracing in injury prevention, athletic performance and neuromuscular control: A review of the literature. Foot 2005; 15: 1-6.
[http://dx.doi.org/10.1016/j.foot.2004.07.002]
-51Ubell ML, Boylan JP, Ashton-Miller JA, Wojtys EM. The effect of ankle braces on the prevention of dynamic forced ankle inversion. Am J Sports Med 2003; 31(6): 935-40.
[http://dx.doi.org/10.1177/03635465030310063201] [PMID: 14623660]
]. Rovere et al. [52Rovere GD, Clarke TJ, Yates CS, Burley K. Retrospective comparison of taping and ankle stabilizers in preventing ankle injuries. Am J Sports Med 1988; 16(3): 228-33.
[http://dx.doi.org/10.1177/036354658801600305] [PMID: 3132864]
] reported that ankle stabilizers were effective in decreasing the occurrence of ankle injuries and that they must be worn whenever exposure to the risk of ankle injury is present. However, it is not advisable to play with a previous unhealed injury under the assumption that tapes and bandages will have a strong preventive effect [27Verhagen EA, Bay K. Optimising ankle sprain prevention: A critical review and practical appraisal of the literature. Br J Sports Med 2010; 44(15): 1082-8.
[http://dx.doi.org/10.1136/bjsm.2010.076406] [PMID: 21047837]
]. This study’s results acknowledge that the use of ankle bracing reduces the incidence of ankle sprain injuries, as well as the incidence of ankle sprain injury recurrences.

We also investigated post-injury treatment measures chosen by the players. Almost half of them preferred to go to the hospital, possibly because of the severity of the injury. On the other hand, only 15.8% selected physical therapy treatment. The explanation involved a lack of physical therapy experts available in the sports field in Saudi Arabia, mainly in the Tabuk region, as well as lack of physical therapy awareness among the soccer players. Furthermore, Saudi Arabia’s healthcare system prevents patients from direct access to physical therapy services, also contributing to this finding. Analysis of injury prevention strategies among the players showed that more than half of them had never received education regarding injury prevention. Increased awareness of the mechanisms of ankle injury among soccer players, in addition to more frequent instruction and education about injury avoidance and prevention, should be addressed by trainers and team physicians. This may play an important role in reducing the incidence rate of ankle sprains in soccer players.

Table 1
Characteristics of the Participants (n = 400).


Table 2
Demographic risk factors for ankle sprain (n = 255).


Table 3
Play-related risk factors for ankle sprain (n = 255).


Table 4
Univariate logistic regression analysis.


Finally, it should be mentioned that to prevent ankle sprains, it is important to employ a multi-disciplinary team approach, involving sports trainers, coaches, physicians, and physical therapists, as well as the players. Raising awareness of the complexity of the situation and improving individual compliance under the supervision of trainers and physical therapists are essential factors. All these factors are important in implementing ankle sprain prevention strategies.

4.1. Limitations

To the best of authors’ knowledge, this is the first study to analyze the prevalence and risk factors of ankle sprain among amateur and professional male soccer players in Tabuk in particular and Saudi Arabia in general. The findings of this study can be expected to contribute to guiding medical and support staff in soccer clubs regarding how to reduce the prevalence of ankle sprain among players. However, this study has some limitations which should be discussed. One limitation is that we did not record the frequency of injury in the dominant side versus the non-dominant side. These recordings could have added important information to the study’s results with respect to the difference in injury occurrence and recurrence between the two sides [53Ekstrand J, Gillquist J. Soccer injuries and their mechanisms: A prospective study. Med Sci Sports Exerc 1983; 15(3): 267-70.
[http://dx.doi.org/10.1249/00005768-198315030-00014] [PMID: 6621313]
]. Yet, we believe that this limitation does not affect the significance of the major findings of the study about the prevalence and risk factors of an ankle sprain. Another limitation is that the study sample was limited to male soccer players. However, this could have a minimum effect on the generalizability of the results because soccer is uncommonly played among females in Saudi Arabia. Finally, the sample was drawn from a single region in Saudi Arabia, which may also affect the generalizability of the results. However, we believe this study could lead to future studies in other regions of Saudi Arabia.

CONCLUSION

Ankle injuries are the most prevalent among lower limb injuries in Saudi Arabian male soccer players, particularly in the Tabuk region. Previous ankle injuries, lack of stretching, lack of warm-up, and not wearing bracing were the highest risk factors for the occurrence of an ankle sprain. Players had little knowledge of injury prevention and education. Our findings suggest the importance of increasing the awareness of 1) injuries and 2) the proper physical therapy measures. This might assist in reducing the likelihood of recurrence of ankle sprain injuries among male soccer players.

LIST OF ABBREVIATION

BMI  = Body Mass Index.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

The study was approved by the Research Ethics Committee of the University of Tabuk, Tabuk, Saudi Arabia (Approval No. UT-73-21-2018).

HUMAN AND ANIMAL RIGHTS

No animals were used for this study. All research procedures in this study were performed in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national).

CONSENT FOR PUBLICATION

Written informed consent was obtained from each participant.

STANDARD OF REPORTING

Strobe guidelines and methodologirs were followed.

AVAILABILITY OF DATA AND MATERIALS

The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.

FUNDING

None.

CONFLICT OF INTEREST

The author declares no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

We would like to acknowledge the support of all of the soccer players who participated in the study and the physical therapy students at the University of Tabuk who helped with data collection.

SUPPORTIVE/SUPPLEMENTARY MATERIAL

Self-Structured Questionnaire.

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