Introduction When it comes to numbers of participants and spectators, there’s little doubt that soccer is the world’s most popular sport. It makes sense, then, that soccer sees its share of musculoskeletal injuries. The majority of soccer injuries affect the feet and legs, with sprains, strains, and ligament injuries of the knees and ankles being the most common. This month’s “Case Connections” focuses on the diagnosis and treatment of four not-so-common soccer injuries. Surgery to Reattach a Thigh Muscle In the December 10, 2014, JBJS Case Connector,Huri et al. present the case of a teenage professional soccer player with a chronic rupture of the rectus femoris muscle. The initial injury had occurred two years earlier when he kicked another player’s foot instead of the ball. Nonoperative approaches had not facilitated a return to running or kicking. At the time of presentation, doctors noted a prominence on the right thigh that was suggestive of a proximal rupture and distal displacement of the rectus femoris muscle. At an isokinetic speed of 240°/sec, the knee extension strength difference between the injured and normal limbs was 40%; pain prevented the patient from being tested at other isokinetic speeds. MRI of the thigh revealed extensive soft-tissue edema and a complete avulsion of the reflected head of the rectus femoris. Figure 1 shows the rupture location preoperatively and intraoperatively.Fig. 1: Arrows indicate the location of the rectus femoris rupture preoperatively (top) and intraoperatively (bottom).Intraoperatively, surgeons moved the muscle belly proximally as far as possible without tension and reinserted the tendon with polydioxanone sutures. Postoperatively, the patient was managed with immobilization in extension for three weeks, followed by full weight-bearing starting at four weeks and eccentric exercises starting at six weeks. The patient was running at two months after surgery, was pain-free at six months, and had returned to his previous activity level within nine months. Two years after surgery, isokinetic testing at 240°/sec showed a knee extension strength difference between the right and left knees of –4%. Noting that “appropriate treatment for proximal ruptures [of the rectus femoris] in professional athletes is not well established,” the authors point out that in a recent case series of excision for chronic tears of the reflected head, only one of five patients was able to return to play without symptoms. Surgical repair in this case, they conclude, “was the main impetus for [this patient’s] ability to return to play.” Ankle Fracture Plus Compartment Syndrome Beekman and Watson reported on a “double-whammy” in a twenty-four-year-old man who sustained an external-rotation ankle injury while playing soccer recreationally. Postinjury radiographs revealed a Weber type-B lateral malleolar fracture with tibiotalar dislocation. After closed reduction of the dislocation, the patient was placed in a plaster splint, discharged, and scheduled for open reduction and internal fixation once the soft tissues had healed. But within twelve hours, he was back in the ER with severe pain and decreased plantar sensation. Measured pressures were high in all four leg compartments, and the difference between diastolic pressure and three of the four compartment pressures was <30 mm Hg. Surgeons emergently released all four compartments, reduced the fibula, and stabilized the lateral malleolus with a plate and screws. Two additional procedures were performed during the following week for wound debridement and attachment of the extensor hallucis longus to the extensor digitorum communis. One year after the injury, the patient was participating in recreational sports, albeit with some functional impairment. He experienced continued weakness of the toe flexors and extensors and residual mild plantar paresthesias. The authors emphasized that time is of the essence with compartment syndrome, and, for that reason, “complaints of pain must not be ignored.” Surgical Fixation of Chondral Fracture in the Knee Nakamura et al. reported on a case of successful internal fixation of a partial-thickness chondral fracture in an eleven-year-old boy who had twisted his knee while kicking a soccer ball. The boy presented with joint effusion and slight loss of knee flexion. MRI and subsequent arthroscopy confirmed the presence of an intra-articular free cartilage fragment. Histologically, the fragment was found to consist of viable cartilage cells, along with spindle-shaped, fibroblast-like cells. Histological examination of the matching defect on the lateral femoral condyle revealed a hyaline cartilage matrix with underlying subchondral bone. After curettage, surgeons fixed the fragment to the base of the lesion with four bioabsorbable pins. After immobilization in an above-the-knee cast at 45° of flexion for three weeks, the patient was gradually allowed partial and then full weight-bearing. Four months after surgery, he had full range of motion with no joint laxity and was performing activities of daily living without symptoms. Histological evaluation of an arthroscopically obtained biopsy six months after surgery showed that the reattached cartilage was indistinguishable from normal hyaline cartilage and that the osteochondral junction appeared to have been restored. The patient was allowed to return to strenuous sports activity, and, at the two-year follow-up, he was symptom-free. MRI at that time showed that the fragment had completely healed to the femoral condyle. The authors speculated that bone-marrow cells recruited to the injured area following curettage participated in the healing process. They also surmised that the notable restoration of the osteochondral junction could have been facilitated by the spindle-shaped cells in the chondral fragment. They suggested that “primary fixation of the fragment might be a better option for exploiting the potential for regenerative healing in young patients.” Rest and Analgesia for Iliac Spine Avulsion Fractures Finally, in a nonsurgical case, Kishta et al. reported on a thirteen-year-old boy who experienced sequential, ipsilateral avulsion fractures of the anterior inferior iliac spine (AIIS) and the anterior superior iliac spine (ASIS) about two years apart. The first injury, confirmed radiographically to be a minimally displaced avulsion fracture of the left AIIS, occurred during a soccer game when the patient twisted and felt a painful snap, with subsequent tenderness over the AIIS. After six weeks of oral analgesia and non-weight-bearing, he was pain-free and had a normal gait, and radiographs showed a healing fracture of the AIIS. Twenty-one months later, the patient felt a pop while lunging during gym class, resulting in pain, an antalgic gait, and hip-flexion weakness. Radiographs revealed an avulsion fracture of the left ASIS. After a similar six-week regimen of rest and analgesia, the patient was pain-free and exhibited full range of hip motion. Fifteen months after the second injury, the patient had no pain, and radiographs revealed healing and satisfactory alignment of both fractures. While isolated avulsions of either the AIIS or ASIS are relatively common in physically active adolescents, sequential, ipsilateral avulsions are very rare. Soccer-related ASIS and AIIS injuries usually result from “kicking the air” or a forceful strike at the goal. In this patient, the first injury occurred in the stance phase, and the authors surmised that the mechanism of injury was similar to that which occurs during the push-off for a sprint. The second injury, they hypothesized, was caused by the sudden forceful concentric contraction of the anterior thigh muscles. Conclusion Orthopaedic team physicians are well in tune with the more common injuries sustained while playing soccer (football). That list would include ACL ruptures, ankle sprains and fractures, and musculotendinous injuries in the thigh and leg. This short list of uncommon soccer-related injuries reminds sports surgeons that the basic principles of evaluating the mechanism of injury, physical examination, and judicious use of imaging must be followed in every instance of managing injured “footballers.”