Have you ever wondered what ankle injuries can affect footballers? Our Consultant Orthopaedic Surgeon, Mr Bal Dhinsa at Benenden Hospital, who is also FIFA accredited in Football Medicine, breaks down the most common ankle injuries and their treatment options.
Ankle injuries are common in both professional and amateur level football. Did you know the most common are lateral ligament injuries? During everyday life, your feet and ankles undergo a lot, especially if you’re on your feet most of the day. However, playing football increases these forces which doesn’t even consider tackling an opponent.
1. Lateral ligament injury
When your foot is rolled inwards as a result of a misstep or tackle, a lateral ligament injury may occur. It tends to worsen if the sole of your foot was flexed at the time of the impact. This injury can vary hugely in its severity – it can sometimes completely rupture.”
If you feel there could be a possible fracture, you will need to seek medical attention to arrange a scan for a diagnosis. The following methods can help to manage this soft tissue injury:
- Rest your limb
- Apply ice
- Elevate your ankle – above the level of your heart
- Apply pressure
Getting the ankle moving early with a rehabilitation programme that takes into account the degree of swelling and pain present at each stage is important for ligament healing.
Specific balance exercises are key to the rehabilitation process as they can improve the position of your ankle joint. These exercises will help prevent re-occurrence of any injuries. There are some exercises you can do yourself, but I would advocate seeking the advice of a physiotherapist prior to this. As the ankle feels more stable, pain and swelling reduces, rehabilitation can progress to more functional exercises.
How to avoid further injuries
Unfortunately, if you’ve had an ankle injury you will be at greater risk of further injuries to your ankle. This is often the case if football players have poor rehabilitation and return to the pitch too quickly.
The exercises mentioned above will help to strengthen the ankle joint and help reduce your risk of further injury. Other factors that can be of benefit include:
- Losing excess weight (thus reducing load on the ankle)
- Assessing for any unusual structures of your foot or ankle
- Management with foot inserts (orthotics) or physiotherapy abnormal biomechanics of the foot and ankle that can be potentially managed with physiotherapy or orthotics
2. Osteochondral lesions
The cartilage lining of your ankle joint is frequently damaged with sprains, as the joint surfaces impact on each other. If this occurs, you will first notice a bruise before a small crack on the surface develops. If this progresses, a cyst may form in the bone below the cartilage surface, forming an osteochondral lesion and sometimes a piece of cartilage may become loose.
The following symptoms are felt: Pain in the ankle joint which worsens with movement and stiffness, locking or catching of the ankle.
If an osteochondral lesion is suspected, a magnetic resonance imaging (MRI) scan is recommended for diagnosis, as well as assessment of location and size of lesion.
Initial management for all lesions should be by protecting your joint (ankle brace or walking boot), rest (crutches), compression (sometimes a compression bandage is of help) and elevation. Analgesics and non-steroidal anti-inflammatory medication may also be used and corticosteroid intra-articular injections may also be considered.
When to seek surgery
Most osteochondral lesions will not heal due to the poor blood supply. With persistent pain and symptoms despite non-operative measures, arthroscopic (‘keyhole’) surgery can be considered for small lesions to stimulate the bone marrow.
For larger lesions (greater than 15 mm) open surgery through a small incision at the front of the ankle (arthrotomy) may be required.
3. Ankle impingement and soft tissue impingement
This typically occurs in the anterolateral (front and side) part of the ankle and results from entrapment of inflamed and/or chronically damaged soft tissue. The player complains of limited ankle mobility and swelling after playing football. MRI scans can help to form a diagnosis, as well as a diagnostic/therapeutic injection of local anaesthetic and corticosteroid.
Initial management is often through physiotherapy and deep tissue massage, as well as following the Rest, Ice Compression Elevation – known as the RICE protocol during acute episodes. If there is no improvement with these measures and injections, it may be necessary for surgery to be considered.
Bony impingement is the result of bone spurs of the ankle. The appearance and symptoms are similar to soft tissue impingement but often tenderness is felt too. An MRI or plain radiograph can help to diagnose you with associated injuries.
When to have surgery
Initial management is the same as for soft tissue impingement, however it is often less effective because motion is more limited. Surgery such as arthroscopic debridement can improve your ankles range of motion, however it is not uncommon to have to repeat the procedure in the future for reoccurrence.
4. Plantar Fasciitis
Football training and matches played on artificial surfaces such as Astro turf, can increase your likelihood of developing planta fasciitis. A sudden increase in activity also puts players at increased risk.
The majority of players with plantar fasciitis can be managed with resting, a rehabilitation programme including plantar fascia specific stretching exercises, and the use of orthotics (shoe inserts). Extra-corporeal shockwave therapy may also be used to complement the physiotherapy. If these measures fail to improve symptoms, dry needling and corticosteroid injections may be recommended.
When to have surgery
If all the above measures fail, and there is calf tightness present, a surgical procedure to ease the tightness maybe required.
How to avoid further injury
Daily stretching, as well as a dedicated warm-up regime, is essential to stretch the calf and foot to prepare for football training. Read our article to learn how to treat plantar fasciitis from our Sports Medicine Podiatrist Mr Liam Stapleton.
5. Tendoachilles tendinopathy
With overuse or repetitive strain, the tendoachilles can be injured and even develop a tear. These injuries heal with scar tissue leading to a swelling of the ankle tendon.
Following a rehabilitation programme of exercises and physiotherapy is essential, as well as developing an understanding between the team and football player about the need not to rush to return to play until fully recovered. Unfortunately, in 2022 there have been examples in American sport teams of players suffering rupture of the tendoachilles following an early return to sports after a ‘calf strain’. The following are common symptoms of a tendoachilles injury:
- Pain and swelling around the injured area (often worse in the morning before stretching and after exercise)
- Thickening appears over the inflamed area which makes wearing footwear uncomfortable
Initial management includes activity modification, incorporating rest periods, modification of footwear with heel lifts and stretching exercises. Analgesics and non-steroidal anti-inflammatory medication may also be used. Early physiotherapy intervention will be required to help aid recovery.
Next steps in management could include an injection of high-volume fluid around the tendon under ultrasound guidance. An alternative is extracorporeal shock wave to help break down the scarring that is often present with inflammation and allows the stretching exercises to be carried out effectively.
When to have surgery
If you’re suffering from persistent pain and swelling, two types of surgical intervention can be considered: non-insertional tendinopathy or insertional tendinopathy.
How to avoid further injury
Daily stretching, as well as a dedicated warm-up regime, is essential to stretch the calf and foot in preparation for playing football again.
6. Ankle fractures
Fractures of the ankle in football players are usually quite severe making acute surgical intervention necessary. Rarely, a fracture can occur at low velocity without direct impact, which results in a minimally displaced fracture which can be managed with rest for six to eight weeks. Once there is evidence of clinical and radiological healing, rehabilitation can be commenced.
Metatarsal fractures are frequently seen in football players, especially with the use of modern football boots which are designed with less ankle protection in order to make them lighter. They may also occur as a stress fracture, especially if activity levels have suddenly increased. These fractures are often minimally displaced and can be managed with rest for the initial four to six weeks to help to control the pain, followed by physiotherapy.
If the fracture is significantly displaced or has failed to heal after non-surgical measures, surgical reduction and fixation may be required. Unfortunately, any metalwork utilised in the fixation may need removal after your fracture is healed as footballers often find this uncomfortable.
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Published on 20 July 2023