Sports-Related Foot and Ankle Injuries: Prevention and Treatment Tips

Foot and ankle pain are disturbingly ubiquitous in daily life and in any given patient population. Specifically, health care workers suffer more lower extremity musculoskeletal injuries than any other occupational group. Additionally, numerous athletic activities, including professional and recreational sports, put an inordinate amount of strain on the lower extremity. The spectrum of pathology ranges from routine overuse injuries, such as tendinitis, to traumatic fractures and ligament tears. These injuries have potential for lingering symptoms and significant functional loss. While some injuries are truly unpreventable, we strive to minimize morbidity related to foot and ankle injury. With medical costs and lost wages factored in, the financial burden related to sports-related injuries has been estimated to be $1.89 billion. By analyzing the causative factors of these injuries and understanding the structural damage incurred, we are better equipped to prevent foot and ankle injuries. This essay covers a comprehensive view of foot and ankle injuries, treatment, and prevention, emphasizing a biomechanical approach. The authors stress that no one particular theory of etiology is definitive for each and every injury, and it is often multifactorial. A solid understanding of normal foot and ankle anatomy and biomechanics is helpful when considering the dynamics of injury and the various treatment options. For purposes of this essay, the spectrum of “sports-related” injuries will encompass traumatic and chronic injury incurred during any athletic activity or competition. This contrasts with other musculoskeletal overuse injuries often seen in non-athletic persons. This first part of the essay focuses on the importance of prevention of foot and ankle injuries, beginning with an in-depth analysis of the structural damage following specific injuries.

Importance of Preventing Foot and Ankle Injuries

An athlete with a foot or ankle injury will often adapt a “gimpy” way of running where they are taking weight off the affected side. This places more stress on the healthy foot and ankle. This can carry over changes in gait pattern outside of the athletic arena. The athlete becomes susceptible to injury on the healthy side because they are accustomed to moving a different way. Finally, ankle injuries have a very high recurrence rate when compared to other sports injuries. 73 percent of athletes who have had a history of ankle sprains using no preventative measures experienced a re-sprain in a one-year period. This is a direct reflection of the earlier stated fact that about practicing being riskier than competition. With this statistic, it is possible that the sprain is being experienced in the process of trying to rehabilitate the original injury. Given the fact that the common sprain has a rehabilitation period from a few days to a few weeks, one sprain can hinder an athlete’s season. The total cost for USA basketball players alone who get ankle sprains and miss time from their given team was estimated to be 8.5 million dollars per year. This is serious effort and money being spent on an injury which is highly preventable.

Preventing foot and ankle injuries in athletes is vital to the overall well-being and long-term participation in recreational activities and sports of the athlete. When an athlete experiences an injury to the lower extremity, they must avoid weight-bearing types of activities for a while. For some types of injuries, this is accomplished by using crutches. So seeking information, for example using these crutches, can lead to various websites which provide a guide to these from a specialist such as Causes and Prevention of Using Crutches where the injury is explained fully. For more severe injuries, especially those requiring surgery, there will often be a long rehabilitation process before the athlete can return to full competitive form.

Sporting activities provide a great opportunity for exercise, camaraderie, and enjoyment. Unfortunately, they also carry with them the potential for injuries, many of which can be catastrophic to the athlete’s participation in sports and other activities later in life. On the bright side, the majority of these injuries are preventable. According to the National Athletic Trainers’ Association, 65 percent of all sports injuries occur during practice. This is good news given the fact that coaches have more control over the safety of the environment in practice situations and can make it safer than competitions.

Common Causes of Foot and Ankle Injuries

Achilles tendonitis is often seen in running and jumping activities and is more frequent in athletes over the age of 35. It can be caused by a sudden increase in the amount or intensity of sport activity. The tendon becomes painful, ropy, and thickened and can lead to a serious injury with a tendon rupture at the calcaneal insertion. This is a long-term injury, which usually requires surgical repair and can take up to 6-12 months before the athlete can return to sport.

Overuse injuries occur with repetitive use of the same part of the foot or ankle, causing a constant low level of trauma. This can happen during training or sport-specific activities, and some injuries have been found to be sport-specific due to footwear and the movements required. Commonly injured areas are the Achilles tendon, the posterior tibialis tendon, and the peroneal tendon area on the outer side of the ankle. These injuries often lead to tendonitis and tendon dysfunction problems.

In addition to traumatic injuries, acute or sudden injuries that occur because of a sudden force, often caused by external factors, athletes also need to be aware of overuse injuries. Traumatic injuries are normally caused by a sudden force or impact and can be caused in a number of different ways, for example, the force can be a result of a collision with another person or dropping an object on the foot. The foot or ankle is forced out of its normal position, causing damage ranging from a simple sprain to a long-standing arthritic change. The most common ankle sprains and fractures occur in football, rugby, and dancing on an uneven surface. Ankle injuries have been reported in studies to make up 10-30% of total sporting injuries. The most commonly identified cause is lateral or sideways, caused by sudden stopping or direction change, mostly experienced during running activities. The injury usually happens because the sole of the foot is twisted inwards, causing damage to the outer side of the ankle and putting stress through the inner side. This can cause damage to the ligaments or ankle fractures. High ankle sprains are also an injury where ligaments above the ankle are damaged due to the foot and leg being forced apart due to an external force. The injuries can be severe and lead to long-term symptoms. Sudden pain is felt and possible swelling and a feeling of ankle instability. Sports with a high ankle sprain incidence rate include football, hockey, skiing, and basketball.

Understanding Foot and Ankle Anatomy

The most common site of injury in the foot is the lateral ankle due to its low level of stability. High-level sprains are also known to cause fractures of the lateral malleolus or, more worryingly, an avulsion fracture of the base of the fifth metatarsal. This can happen with an incorrect diagnosis and rehabilitation as the patient continues to participate in heavy activity on an already weakened ankle. An avulsion fracture can be hard to distinguish from a sprain as this too is caused by forceful inversion of the ankle. A high ankle sprain is the result of disruption or damage to the syndesmotic ligaments that connect the tibia to the fibula. This is usually caused by dorsiflexion of the ankle and is common in American football and other high-impact sports.

The foot, as seen in Figure 1, is a complex structure made up of 26 bones and 33 joints. It is required to adapt to uneven surfaces, provide a stable platform, absorb shock, and propel the lower limb in a forward motion. A successful gait cycle is therefore dependent on adequate function of the foot. If an injury is sustained in one part that disrupts normal activity, it can have a profound effect on normal function.

Unlike a classic injury location such as the hip or knee, every sports-related foot or ankle injury has a profound consequence on weight-bearing function. This is for the simple reason that the foot and ankle are responsible for the generation of the majority of the ground reactive forces in the lower extremity. Most injuries are caused by a sudden twist or change of direction. Sometimes all it takes is stepping awkwardly on an uneven surface to feel the pain.

Prevention Tips

In many cases, there are inadequacies in the available data associated with specific injuries in particular sports. With the importance of knowing the predisposing factors to injury so high, more epidemiological research is needed in individual sports in order to design injury prevention strategies. This will also facilitate the monitoring and identifying of points in which prevention strategies can be implemented to improve player safety. The eventual adoption of injury prevention strategies into the culture of sport will be the most important way to improve player safety. This can be achieved through rules and regulation changes, change in coaching philosophies, conditioning programs, and lastly education of players and coaches in prevention strategies.

Due to the increase in the trend of injuries to the foot and ankle that are sports-related, identification of this problem is crucial. A combination of several factors contributes to the rate of injury in sports. These factors include: – Increased fitness/athleticism of participants – Change in leisure time activity to more sports – Change in footwear to lighter, more flimsy materials – Increase in participation of high-risk sports by persons of all ages

Proper Warm-up and Stretching Techniques

There are three stages to a warm-up. The first is a period of low intensity exercise, e.g. jogging. This is to slowly increase body temperature and heart rate. Static stretching comes next. This is where a muscle is taken to the end of its range and held there for several seconds for 5-10 repetitions. Static stretching as part of the warm-up has been given some negative reviews recently. However, the majority of research shows that it can have various positive effects on muscle performance and injury prevention. Static stretching should be followed with some dynamic stretching. This is where muscles are taken through their full range of motion in a series of controlled movements. Static and dynamic stretching combined are ideal to increase muscle and joint elasticity.

A good warm-up is essential before starting any sports activity; this is a very important step in preventing injuries. A well-structured warm-up will slowly increase your heart rate, body and muscle temperature, which in turn will increase blood flow to the muscles. Increased blood flow to the muscles will increase their metabolism and in turn make the muscles less viscous and therefore more elastic. This makes the muscles less prone to injury such as strains and tears. Ligaments around the joints are less viscous than muscles; they are viscoelastic and so require more time and a gradual increase in temperature to reach their optimal elasticity. A good warm-up will also initiate nerve impulses more effectively. This will improve muscle reactions and the speed of these reactions. The improvement in neuromuscular reactions and muscle metabolism may also improve muscle strength and power. Finally, the warm-up also mentally prepares athletes for more strenuous exercise by increasing their alertness and improving their concentration.

Choosing the Right Footwear for Sports Activities

There have been large amounts of research into how much a shoe affects an individual’s biomechanics. The general findings have been that motion control shoes can reduce the amount of pronation or supination of the foot. The cushioning of a shoe can reduce the stress on the foot and leg that occurs during activity. Subsequently, it is vital for an athlete to buy a shoe that is specifically suited to the specific stresses of their sport and their biomechanical pattern. A podiatrist or sports physician can help guide you to the correct type of sports shoes for your activity and also advise on orthotics if necessary.

In order to prevent this damage from occurring, you would need a higher shoe with a firmer heel counter to control the rear-foot motion. A good quality walking shoe has to be flexible and supportive. A sports shoe is designed to absorb the shocks and impact of a certain sport and protect the foot from the stresses of the sport. In some sports, the sports shoes need to be especially designed to protect the foot from the specific stresses and potential injury of the sport.

It is imperative that you wear the right sort of shoes for the sport that you are participating in. Research shows that during running there is up to 3-4 times your body weight being put through the foot. This is being increased by the speed that you are running. There is a possibility of 1000 pounds of force being placed through the foot. During impact, there is also a risk of the foot sliding forwards in the shoe. This can lead to increased pressure on the toes and, in some cases, cause black toenails.

Strengthening Exercises for the Foot and Ankle

– Toe curls: This is a simple yet effective exercise that can be done anywhere. While seated, place a towel on the floor and use the toes to scrunch it up and then spread it about. This is a great exercise for improving strength and coordination of the foot muscles.

– Theraband exercises: Using a theraband, tie it around the foot and move it in four directions against resistance. Moving the foot up (dorsi flexion) and down (plantar flexion), and in and out. This will help to isolate the specific foot and ankle muscles and is important in retraining them post injury.

– Calf raises: These can be done on a step, going from the toes all the way down to the bottom of the movement. Doing this exercise with a bent knee will help to isolate the soleus, which is an important stabilizer of the ankle during and after movement.

As always, a proactive approach is the best method of defense against an injury. Strengthening the foot and ankle is often the best step to help prevent injuries from happening. As mentioned earlier, the foot and ankle contain many stabilizing structures, and when these are weak, it becomes easier to injure the area. There are both intrinsic and extrinsic muscles in the foot, and they must all be strengthened for the best possible stability outcome. Here are some exercises to help with this:

Maintaining a Healthy Body Weight

It is recommended to keep track of daily food and caloric intake. This can be done by keeping a food diary and inputting the information into one of the many calorie tracking websites available today. By doing this, one can determine how much food one is eating relative to what their body requires. If a day’s worth of eating does not exceed an individual’s caloric requirement, body weight will remain constant. If one eats more than what is required by the body, the excess calories will be stored as fat and weight will be gained. On the contrary, if an individual eats less than their required amount, the body will utilize the stored calories in the fat to make up for the energy deficit, and weight will be lost.

Eating a healthy diet and making the right food choices is essential for the improvement of overall health and specifically our weight. There are several diets on the market that promise weight loss, but it is recommended to achieve weight loss and maintain a healthy weight with a balanced diet. The premise of a balanced diet is relatively simple: eat a diet that consists of a variety of different food groups, focusing on the ones that are healthier and more nutrient-dense, and watch your portion sizes and total caloric intake. Although this sounds simple in theory, behavioral changes relating to food are one of the leading causes of obesity in our society.

Avoiding Overtraining and Fatigue

It is important for athletes to be aware of what their body is telling them. The 10% rule is a safe way to increase training intensity, duration, or distance for running and aerobic exercise. Increase weekly training mileage by no more than 10% per week. If there is any pain in the lower extremities, it is vital to decrease the intensity and/or duration of training to allow the tissues to heal. Ignoring pain is a recipe for disaster. Often times athletes do not know the difference between pain and injury. Warning signs of chronic injury include: pain that does not go away with rest or continues to get worse, swelling, and decreased performance in physical activity.

Overtraining and fatigue are often the common cause of many overuse injuries and sports injuries in general. In this day and age, more is better. The common misconception is “If I work harder than my opponent, I will be sure to outperform him/her.” The truth is, we all have heard the story of the tortoise and the hare. Being the “hare” does not always bring the best results. Training intensity and duration should be increased gradually over time to avoid overuse injuries. It is imperative to have at least 1-2 days off per week from training or a sport to allow the body’s tissues to rebuild. Sleep is often the first thing we give up with our busy lives; however, getting adequate rest is essential for tissue repair and to prevent fatigue. A healthy diet and maintaining a healthy body weight are essential for giving your body the energy it needs to train effectively and recover from exercise. Failure to maintain a healthy diet and body weight can lead to a decrease in bone density.

Treatment Tips

Pain management techniques: There are numerous ways to deal with pain, the most common is the use of over-the-counter drugs. Ibuprofen is commonly used due to its ability to reduce pain and swelling; however, it is important not to use it for the first 48 hours post-injury as it may impair the healing process. Next is Tylenol, which is used to reduce pain but has no effect on swelling. Topical analgesics are used to achieve pain relief without the use of drugs. These come in the form of creams, gels, or sprays and can be used multiple times a day for pain relief. If pain persists, you must see a physician to further assess the injury and the need for stronger prescription drugs.

Rest, ice, compression, and elevation (RICE) is used to treat many sports injuries, not just foot and ankle injuries. The primary goal is to decrease the metabolic rate of the cells within the damaged tissue, lessening the possibility of secondary damage and limiting the amount of inflammation and subsequent swelling. The cold slows down the blood flow to the injury, further minimizing swelling and pain. When icing an injury, it is important to use a damp cloth between the ice and the skin and ice the injury for 15-20 minutes every 1-2 waking hours for the first 48 hours or until the swelling goes away. Compression is used to decrease the swelling (edema) associated with an acute injury. This is done by the application of a compression wrap, which should be snug but not cause more pain or swelling. Elevation helps to prevent the pooling of blood and lymphatic fluid within the injury, which causes swelling and pain.

Rest, Ice, Compression, and Elevation (RICE)

The R.I.C.E. method has been used for many years and has been proven to be effective in treating minor injuries, as well as a precursor to and rehabilitation regimen following surgery. This method is most effective with a combination of therapeutic ultrasound. Ultrasound coupled with the usage of ice in the initial R.I.C.E. step may, in fact, yield better results than just using ice alone. But be aware of the temperature of the treatment area during ultrasound, as the cold modality of ultrasound may have adverse effects.

The final step in the R.I.C.E. method is elevation of the injured area, which also helps reduce swelling. If the area is swollen and it is difficult to place weight on it, it is probably more comfortable to elevate the injured area. If it is an extremity injury, such as an ankle sprain, elevation should be above the level of the heart for at least 50% of the day. This is to ensure that swelling is kept to a minimum.

Compression is the third step and is used to help reduce swelling in the injured area. Use a tubular compression bandage to the chase swelling away from the injured area. Make sure the bandage is snug, but not too tight where it could act as a tourniquet. Compression should be applied in the first 24-48 hours following the injury, but ice and compression can be used as long as swelling or pain persists.

The second step is to ice the injury to help control inflammation and to help alleviate pain. Do not apply the ice directly to the skin, but use a pack or crush the ice and wrap it in a towel. Applying ice directly to the skin may result in a cold burn. Ice should be applied for 20 minutes, no more than 8 times per day.

During phase one, using the injury of an ankle sprain, the patient will need to rest to avoid any additional stress on the injured area. They will also need to restrict weight-bearing on the ankle depending on the severity of the sprain. Immobilization of the ankle will have to take place using a bandage, taping, or an ankle brace.

Treatment for soft tissue injuries (sprains/strains/contusions) is often remembered by the mnemonic R.I.C.E., or rest, ice, compression, and elevation. Three of these four steps are used in the first 24-48 hours following the injury.

Pain Management Techniques

PRICE is a combo used in the early injury phase which also has a nice ring to it. Protection is especially relevant for severe injuries and during the first few days. Rest is not meant to be prolonged, and it is important to maintain a level of fitness by engaging in alternative forms of exercise. Crutches may be advised in cases of severe acute injury or where there is significant pain. Relative rest is a reduction in the volume and/or intensity of weight bearing or activity. This can be gauged by pain monitoring and should be done in conjunction with an alternative aerobic exercise such as swimming. Immobilization may be required for 1-3 weeks in some injuries, and this can result in significant loss of muscle condition and reduced strength. In these cases, a rehabilitation program is important to ensure a timely return to normal function.

Pain management is important for anyone with a foot or ankle injury as it may be the major determinant for needing crutches or being able to return to proper function. Pain is generally due to local swelling and inflammation resulting from micro trauma. This may keep a person from using the injured part and lead to chronic dysfunction if not treated early. Avoiding harmful activities and taking NSAIDs for the first 48-72 hours is key in this early protection phase. The inflammatory phase is typified by pain at the start of an activity which often eases off until the activity is stopped and there is pain following the activity. In severe injuries, there may be pain during rest. The repair phase has pain only after heavy or prolonged activity. If activity is continued despite recurrent pain, the injury may enter the doom phase with chronic persistent pain or diffuse pain and swelling.

Physical Therapy and Rehabilitation Exercises

Over the years, the idea of rest, crutches, and immobilization has been tossed to the side, and physical therapy has been promoted for both caretakers and patients to regain range of motion and strength, with beneficial short and long-term outcomes. Passive range-of-motion exercises maintain joint flexibility, obtain normal joint mechanics, and minimize contracture formation. At the beginning, gentle stretching of involved soft tissue structures is performed to increase extensibility and flexibility. This should occur before strengthening exercises since tight musculotendinous units can tear if subjected to resistance too soon. In the case of an Achilles tendon repair, an ankle sprain, or an ankle fracture, it is essential to normal functional recovery that the length of the gastrocnemius soleus complex is elongated to baseline values. If an ankle has been immobilized for any length of time, a joint mobilization should be performed to decrease joint stiffness and realign fibers that may have formed haphazardly due to immobilization and inconsistency of ligament fiber repair. Another goal is to regain a functional strength level that will allow the patient to return to prior activities or sports. Isometric exercises initiate muscle recruitment without joint movement, protecting repair and healing. Open and then closed chain isotonic exercises progress from muscle activation without joint movement to the coordination of muscle groups on a specific joint and finally to coordination of muscle groups and joint stabilizing muscles for a specific limb function. Finally, isokinetic muscle actions are addressed to improve strength and coordination, and power or functional exercises are performed to associate strength levels with specific activities. Functional progression is a return to activities and sports-specific exercises and will be discussed further in this paper. Flexibility, endurance, strength, and power must be addressed with the understanding that there is an optimal sequence, and education is required to advance a patient or athlete.

Using Supportive Devices and Braces

After an acute ankle sprain or immediately following surgery, a brace, cast or other form of immobilization may be required to assist in healing. The type of support recommended will vary depending on the severity of the injury, the chosen treatment, and the professional opinion of the doctor or surgeon. A subjective assessment will be made to determine the appropriate support. This will include balancing the benefits of the stability provided by the immobilization with the potential negative effects of immobilizing for too long. Studies have shown that the degree of immobilization directly relates to the increase in abnormal gait patterns and a decrease in function. These changes can affect the recurrence rates of ankle sprains and long-term ankle function. A 2-3 week period of immobilization is usually recommended, using a semi-rigid or soft cast and allowing for restricted weight-bearing. The ankle should then be allowed to progressively move into weight-bearing and restoration of a normal gait pattern with the removal of the immobilization. On occasions where it is determined that the ankle will be subject to a high risk of re-injury, an ankle brace may be chosen for long-term use.

When to Seek Professional Medical Help

– Pain, swelling, or stiffness in a joint or foot that does not improve within 48 hours. – Inability to walk more than four steps without pain. – Pain that continues even when you are not bearing weight on the foot. – Severe pain and swelling in the toes. – Pain on the underside of the foot in the heel or in the arch that continues for more than two weeks. – Numbness or tingling that does not subside within 24 hours. – Weakness in the foot or ankle.

If you have sustained a sports-related foot or ankle injury, knowing when to seek professional medical help is very important. A good rule of thumb is to remember that any injury that produces severe pain, swelling, discoloration, or that you are unable to bear weight on should be evaluated by a physician.

The amount of information on various foot and ankle injuries can be great, but these are, in fact, only a small group of relevant sport articles. However, an understanding of the causes and mechanisms of these types of injuries, how to best manage and prevent them, is critical for athletes and their coaches. The consequences of a foot or ankle injury leading to permanent disability can be devastating and have far-reaching effects on an athlete’s long-term health and athletic career. With this in mind, it is alarming to see very little published evidence on the long-term effects of these injuries and whether the management strategies employed in the early 21st century are, in fact, optimal. Hopefully, over time, such evidence will become available, and future generations will benefit from this in the management and prevention of these injuries.

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