Football is one of the most popular sports played at the youth, high school, and collegiate level. Due to frequent impact forces, foot and ankle injuries are common. This article will discuss common foot and ankle injuries associated with this sport and how these injuries are often treated.
Plantar Fascia Injuries
One of the most common structures injured in the foot, the plantar fascia is a ligament that passes on the bottom of the foot from the heel bone forward to the base of the toes. In sports that involve sustained running like soccer or cross country, injury to this tissue is more subtle and involves inflammation and microscopic tearing the tissue tissue (plantar fasciitis). In football, while plantar fasciitis does occur, the injury to this tissue is often more specific, and involves more forceful tearing or even rupturing of the tissue. Plantar fascia ruptures are seen when there is a strong push off force during explosive running or cutting, and linemen accelerating out the three point stance can also lead to this injury. The pain of either a plantar fascia rupture or simply plantar fasciitis is usually felt on the inner side of the bottom of the heel where it meets the arch, although some ruptures can be felt more closely to the middle of the arch. While ruptures can eventually heal, if untreated they can eventually lead to chronic plantar fasciitis which can persist for years. Plantar fascia rupture treatment involves a short period of rest and immobilization in a walking boot to allow the tissue to heal, followed by arch support or taping and gradual return to the field. Treatment of fasciitis is fairly simple, and involves gentile stretching, inflammation reduction, and orthotics ( specialized shoe inserts) to provide greater foot support. Surgery is uncommon.
Ankle Sprains
Ankle sprains are common injuries in sports. While it is often assumed ankle sprains in football occur because of the force of an opponent landing on another player’s ankle, it is also just as common for sprains to be self-caused, such as through one performing a cutting motion, or sharp acceleration or deceleration. Since the upper body moves faster than the feet, the foot may remain planted on the ground, leading to a twisting motion at the ankle during these hard movements. Divots and uneven surfacing of the ground can also lead to these injuries.
On the outside of the ankle, there are three separate ligaments: one toward the front of the ankle, one along the side, and one towards the back. These ligaments connect the outermost bone prominence of the ankle to one of the bones of the back of the foot. Most athletes roll their ankle inward during an injury. This motion stretches and tears the ligaments on the outside of the ankle. Usually the first one or two ligaments are injured in a sprain, although severe sprains can involve the final ligament near the back. Sprains in which the ankle rolls outward are uncommon. The inside of the ankle is held by a very strong ligament structure that acts as a single unit. It is difficult to sprain this side of the ankle due to the strength of the ligament, and therefore sprains on this side do not occur with great frequency.
Ankle sprain symptoms include swelling, warmth, bruising, and of course pain following the injury. These symptoms do not necessarily show up at the exact time of the injury. In some cases, the symptoms can be delayed by a few hours. Additionally, a feeling of ankle weakness is also common, due to extra laxity of the ankle joint developing from the ligament tearing. Pain with standing or walking is to be expected. Severe pain in which one cannot even place the foot down without excruciating pain possibly indicates a major fracture in the ankle or foot. The same is true for any sprain in which the ankle looks deformed or is angled off to one side. Several smaller foot fractures have been associated with ankle sprains, which do not necessarily add to the pain of a typical sprain directly. These often go untreated as people assume the pain was solely due to the sprain itself. In essence, a medical evaluation with foot and ankle x-rays is needed for all severe sprains, and most moderate sprains as well.
‘High’ ankle sprains are a somewhat different and more serious variation of the traditional ‘lateral’ ankle sprain, and involve damage to the tissue (syndesmosis) that binds the end of the leg bones that comprise the top part of the ankle joint. The pain is felt primarily above the ankle, and x-rays may indicate separation of these bones.
Treatment of any sprain begins with the usual formula of rest, ice, compression, and elevation, primarily to reduce inflammation and improve comfort. The ankle will need support in order to heal, even if pain is minimal. The use of an ACE bandage or a stretchable ankle sleeve is helpful for very low grade sprains in non-athletes, but is probably of little use in an athlete trying to decrease recovery time. More substantial bracing is often recommended, along with physical therapy as soon as the pain will allow. Sprains that are moderate to severe (or high ankle sprains) may require more aggressive treatment, including a period of immobilization prior to advancement to physical therapy. These injuries obviously take much longer to heal. All sprains should have a medical evaluation, including x-rays, to identify any significant instability, as well as any small fractures that may involve the bones surrounding the injury site. Further tests may need to be done if a full ligament tear is suspected, including the use of an MRI scan. Surgery is sometimes indicated to repair ligament tears that remain chronically unstable, or to immediately repair fractures that occur with the injury. Surgery is also sometimes needed in high ankle sprains.
The long term complications that can occur with an untreated or under treated ankle sprain include instability, pain or stiffness in the ankle joint, ankle arthritis, and frequent spraining due to the inherent weakness of the injured ankle tissue. These symptoms can last a lifetime, and can make even simple walking difficult, especially on uneven surfaces. Proper initial treatment guided by a foot and ankle specialist can help prevent these complications, and lead to a lifetime of healthy ankle function.
Turf Toe
Turf toe is a common sports injury that involves a sprain to the great toe joint. It is called turf toe as it is commonly experienced by those who play on artificial turf surfaces. This injury can have two different causes. More commonly, the toe is injured when it is pulled upward on a hard surface, causing tearing of the tissue on the bottom of the joint. Less commonly, the toe is injured when it is flexed downward and tissue on the top of the toe is torn. The injury may be minor enough that it is not really noticed at first, and the pain may be dull enough that the athlete continues to play on it. This eventually leads to a worsening of the injury, and can make healing time far more extended.
Football players are at risk for this injury through several mechanisms, including tacking, forceful push off of the great toe during blocking, as well as injuries from landing after a catch or from kickers striking the ground.
Common symptoms include pain, and swelling of the big toe joint, especially when the toe is pushing off of the ground. The motion of the joint can eventually become restricted due to the pain, and the skin around the joint can appear black and blue due to bleeding incurred from tissue tearing. The toe will be more painful while barefoot or in lighter, more flexible shoes, and up to half of the people who develop this injury will have long term pain issues.
Treatment is centered around a combination of icing, rest, anti-inflammatory medications, and stiff shoes. Strapping or taping the toe can help an athlete return to activity quicker, and the use of a prescription orthotic insert can provide support for the great toe joint from underneath. The time away from the sport varies by the severity of the injury. Minor cases may only need a few days of rest, while more significant cases may need one to two months of rest. Physical therapy is sometime necessary. Severe cases may need cast immobilization or surgery outside of rest from sports to allow for full healing.
Toenail Injuries
Bruised nails are common, and are seen in football usually when one gets their toes stepped on by another player, or when a tight, poorly fitting shoe causes gradual pressure damage to the nail and the skin below it.
As blood pools under the nail plate, it will turn the color of the nail blue, purple, or eventually black. This color will stay in the nail until the new nail grows outward, where the discolored area will be pushed slowly towards the toe tip. The blood will be liquid initially, and then will eventually dry up into a powder.
Bruised toenails may often be painless, but they also can very painful, limiting performance. Fractures of the bone underneath the nail can also be present, and it is the protrusion of the bone from underneath that sometimes is the cause of the bruising, especially in cases where most of the nail is bruised.
Small bruises involving a quarter or less of the nail’s total size are often left alone, and allowed to grow outward. Larger bruises may require removal of the nail to help drain the blood and prevent infection, and allow for inspection of the skin underneath the nail for any cuts that need to be repaired or bone fragments that need specialized treatment to avoid bone infection. The nail will eventually grow back, although sometimes the injury that caused the bleeding in the first place may be severe enough to damage the nail root cells, leading to a permanently thick or strangely shaped nail. Nail bruises that are painful must be evaluated by a podiatrist or other physician to ensure that a fracture or significant skin injury has not occurred, and any nail discoloration that does not grow out with the nail needs a similar evaluation to rule out nail fungus or a more serious condition.
Metatarsal Fractures
The metatarsals are the long bones in the middle of the foot that end at the bases of the toes. There are five total, just as there are five toes. These bones can be broken in a variety of different ways when playing football, including being forcefully stepped on, being caught in a pile up, as well as when making a hard cut. The 5th metatarsal can be fractured in a particularly nasty way during twisting force on the foot, leading to the infamous Jones fracture at the base of the bone. Overall, metatarsals can break at their bases in the middle of the foot, in the middle of their shaft, or at the neck and head of the bone where it meets the initial toe bone. Metatarsal fractures can occur either alone or in multiple numbers, and some injuries can create multiple fractures in a single metatarsal.
The symptoms of a metatarsal fracture usually include pain, swelling, bruising, and warmth in the foot. The middle or front part of the foot will be painful to walk or stand on, and may be painful to move. In some cases, the symptoms may be minimal and difficult to notice initially, with more pain in the weeks following the actual injury.
Treating metatarsal fractures varies by which metatarsal is fractured, whether the fracture has moved the bone out of alignment, or how stable the bone is during the healing process. Many metatarsal fractures can be easily healed by limiting weight bearing pressure using a walking fracture boot. The healing process is usually six weeks, especially in healthy athletes. More unstable fractures or multiple metatarsal fractures require the use of a cast and crutches for support and complete limitation of weight bearing. If the fracture has moved out of place, it must be returned to a proper position by either externally manipulating the fracture back to a proper position, or by surgically repairing the fracture and securing the bone with medical hardware. Surgery is often necessary for Jones fractures in athletes (the base of the 5th metatarsal bone on the outside of the foot), as this area is often unstable.
Achilles Tendon Ruptures
Achilles tendon injuries and ruptures are common, can be quite disabling to an athlete, and full recovery of this injury is often lengthy.
The Achilles tendon is a strong, large, strap-like tissue that connects the two calf muscles to the heel bone, allowing the leg to flex the foot downward. Without this tendon, the foot would uncontrollably flop upward during the walking cycle. Ruptures and simple injuries can occur for a wide variety of reasons. The most common injury in football occurs in quarterbacks, with repetitive dropping backward, decelerating, and firmly planting the foot down. This ongoing action gradually leads to tendon degeneration, and the potential for rupturing. Ruptures can also occur when the foot is flexed upward forcibly while one is pushing downward, or sometimes when the back of the heel is forcibly kicked.
The typical area of rupture occurs at a place above the heel bone where there is poor blood flow to the tendon tissue. A rupture will feel sharp and stabbing, and often a pop or snap is heard. The calf can feel like it has been hit from behind. Walking is extremely difficult, and after the rupture the ability to rise up on the toes is lost. The back of the heel can become swollen and bruised, and there may be a indentation in the heel where the Achilles tendon rupture has formed a gap. Simpler tendon injuries, such as overuse inflammation, or tendonitis, have less pain severity, and while athletes typically play through the pain, the damage of untreated tendonitis can worsen and eventually lead to a hight chance for rupturing.
Treatment of Achilles ruptures in athletes usually requires surgery to repair the severed ends of the tendon together. The sooner the repair can take place, the easier the tendon ends will heal together. Lengthy delays in repair, especially those months in duration, will often lead to scar tissue, tendon degeneration, and a widening of the gap between the severed tendon ends. This makes repair very difficult. Once the ends are stitched together, the foot is held in place within a cast for four to six weeks as the tendon heals. Physical therapy is usually started soon afterwards to restore strength and flexibility. Tendonitis is often treated with stretching, bracing, and physical therapy. Surgery is performed in cases that do not improve to repair and strength the tendon tissue.
Final Note: Other Various Foot and Ankle Injuries
There are many kinds of foot and ankle injuries football players endure beyond the major injuries list above. These include common nuisance injuries like contusions, in which there is bleeding under the skin or within deep tissue from being stepped on by another player. Contusions are painful, but generally heal well with a simple treatment course of ice, elevation, compression, and time. Most players can play through the discomfort of all but the most severe contusions.
Another injury found somewhat uniquely in football is injury and inflammation of the os trigonum, which is a bone found behind the ankle. Not everyone has this roundish small bone, which site on the back of the ankle joint just above the top part of the heel bone. This injury is seen in linemen, whose regular positioning in the three point stance exerts compression of this bone into the heel bone. The resulting inflammation can cause pain when the ankle bends downward. Damage can also occur to the tendon that flexes the big toe downwards, as the tendon runs near the os trigonum on its way into the foot.
Poorly fitting cleated shoes can cause numerous shoe-related injuries to the foot. These can run the gamut from nail and skin bruising, to friction blisters, as well as ingrown nail pain and nerve entrapment. A properly fit cleat is vital for performance, and should neither be sized too small nor too big.
Finally, sesamoiditis is a condition somewhat related to turf toe, in which there is inflammation and possibly even fracturing of the sesamoid bones. The sesamoids are two small egg-shaped bones found under the big toe joint, just behind where the toe meets the foot. Chronic, stressful activities such as high impact jumping or running on a artificial turf surface can lead to inflammation and bruising of one or both of these bones. Eventually this damage may lead to stress cracks of the bone. Immediate injuries can even occur, causing outright fracturing of the bone if the injury force is severe enough, and this can also be seen with long term stress damage if the bone is weakened without relief. The pain of this condition is felt just underneath the big toe joint, usually in a very specific location. Pressure on the inside ball of the foot becomes painful, and running or jumping will become difficult. Unless a fracture has occurred, swelling and bruising are usually not seen. Treatment centers on reducing the inflammation by reducing the stress to this site, using special pads or prescription inserts which direct pressure away from the sesamoids, as well as icing, rest, and anti-inflammatory medications is also used. More serious injuries may need to be immobilized in a walking boot for a few weeks to months depending on the severity, and fractured sesamoids that wont heal may need to be removed surgically.
Scott R. Kilberg DPM 