Few would argue that football is one of the most popular sports in the United States. There are an estimated 1.5 million high school and junior high school players, and 75,000 college and university athletes who play the sport. Football also has one of the highest injury rates among high school sports. The number of football-related injuries is estimated at 600,000 per year.
The care of football injuries occupies a unique place in sports medicine in the United States. Given the relatively small number of games in each season and the potential for college scholarships (and financial rewards for professional athletes or those on the verge of becoming pro athletes), there is perhaps greater pressure on the sports medicine clinician to return the athlete to competition than in any other sport.
As podiatric physicians, we must not only know the common injuries that occur in this sport and the types of footwear used, we also need to have a familiarity with the large number of specialized positions in the sport. Each position requires a wide variety of skills including throwing, catching, running, blocking and tackling. Each of these positions requires certain athletic skills and a specific training regimen. Each position also predisposes the athlete to different types of injury, which may have different requirements for rehabilitation and a subsequent return to play (see “A Guide To Common Lower Extremity Injuries At Different Positions” below).
Ankle injuries are the second most common injury in football and rank just behind knee injuries when it comes to the amount of time lost from playing. Most of these injuries are sprains that players sustain when cutting and changing directions. They usually involve supination of the foot that causes injury to the lateral ligament complex. Another common mechanism involves pronation with external rotation of the talus. This may occur when the athlete’s body is twisted away from the injured side or when another player falls on the posterior aspect of a downed player’s leg.
Differentiating between a lateral ankle sprain and a “high” ankle sprain or syndesmosis injury is important. Syndesmosis sprains require much longer rehabilitation time. If radiographs suggest widening of the syndesmotic space, this may indicate the need for surgical treatment.
Treatment for lateral ankle sprains includes protection, rest, ice, compression and elevation. One should initially protect severe, acute ankle injuries with a posterior splint. When treating a grade 1 or 2 sprain, clinicians should replace this splint with a functional brace to allow early rehabilitation. If one suspects a serious fracture, apply an “L and U” (sugar tong) splint for transport to the hospital. Rehabilitation should include strengthening and proprioception exercises. Upon an athlete’s return to play, he may use braces, taping and high-top shoes for protection. Reserve surgical reconstruction for those with symptomatic chronic ankle instability.
The frequency of ankle sprains in football has prompted many attempts to prevent such injuries with some form of stabilization. The most commonly used method is ankle taping although the cost of this technique in terms of materials and time has led to the use of reusable strapping or braces as an alternative.
Studies of these techniques have attempted to determine if they actually restrict excessive ankle motion and if they reduce the risk of injury. While studies found taping did indeed restrict ankle inversion-plantar motion, the researchers also found that 10 minutes of exercise reduced the net support strength of the taping by 40 percent.
Studies to measure restriction of motion associated with an inversion ankle sprain both before and after 15 minutes of zigzag running found that taping did restrict these motions an average of 27 percent compared to the untaped control. While taping appears to have the potential to protect athletes from inversion sprains, the effectiveness of taping decreases during prolonged use.
Further studies have shown that braces can offer similar resistance to inversion but with the additional advantages of reusability and adjustability during competition. Although athletes and coaches are sometimes concerned that using such devices may reduce performance, a study found such reductions were only 4 percent or less on several performance tests. Researchers also determined that among athletes with a history of prior ankle injury, a combination of ankle bracing and coordination training on an ankle disc could greatly reduce the incidence of re-injury. Among athletes with no history of ankle injury, neither a brace nor coordination training appears to reduce the risk of injury.
Midfoot sprains are much less common than ankle sprains. While these injuries can be misdiagnosed as ankle sprains, a thorough physical examination can usually differentiate between the two. Players with lateral tenderness return to play sooner than those with medial or global tenderness, which tends to sideline the player for extended periods of time.
Probably the most common injury that has plagued many a quarterback is an overuse injury to the Achilles tendon. Achilles tendon ruptures can be caused by the repetition of dropping back to throw the football. A quarterback may throw the football up to 50 times in a game and a few hundred times during practice.
This repetition of dropping back, decelerating and planting the right foot for a right-handed quarterback can lead to Achilles tendinitis that can cause gradual degeneration of the tendon. The tendinitis weakens the tendon and makes it susceptible to tearing. The tendon can also tear from the trauma of a one-time violent deceleration and planting motion without any previous problems with the tendon.
Diagnosing an Achilles tendon rupture is fairly easy with the Thompson test. In many cases, one can use palpation to detect a defect in the tendon. Surgery is usually the treatment of choice for Achilles ruptures among athletes.
Turf toe is a condition that involves injury to the first metatarsophalangeal joint (MPJ) complex. The use of lightweight, flexible shoes on hard artificial turf reportedly increases the frequency of this injury. In one study, 83 percent of the patients reported that their initial injury occurred on artificial turf. The usual mechanism is forced dorsiflexion of the first MPJ joint, which causes stretching of the plantar structures and impaction of the proximal phalanx on the dorsal metatarsal. This often occurs when a player falls on the posterior aspect of another player’s leg. Pain during push-off, swelling, decreased motion and tenderness at the dorsal or plantar aspect of the joint are typical symptoms with these injuries.
One should evaluate radiographs to rule out associated fractures, including fractures of the sesamoids. One would grade injuries to this complex according to their severity. Grade I injuries are marked by local tenderness without swelling or ecchymosis. Grade II injuries have swelling and ecchymosis, and tenderness may be less well localized. Grade III sprains have more marked tenderness, primarily dorsally, and probably represent a spontaneously reduced first MPJ dislocation. The initial treatment for all grades of turf toe is rest, ice, compression dressings, elevation and nonsteroidal antiinflammatory drugs (NSAIDs).
One can usually treat grade I injuries effectively with conservative measures. Athletes may continue sports activity if they wear stiff-soled shoes to reduce dorsiflexion during the push-off phase. They should also tape the great toe by bringing the tape from the dorsal surface of the great toe to the plantar surface. This also limits the amount of dorsiflexion.
Athletes with grade II injuries should refrain from sports activities for one to two weeks and wear stiff-soled shoes. Athletes can insert a rigid orthosis to further prevent dorsiflexion of the first MPJ. Grade III injuries require the same modalities as grade II injuries but the restriction of athletic activities should be three to six weeks. If these conservative measures fail for grade III injuries, surgery for plantar capsular repair or loose body removal may be necessary.
The effects of shoe design and playing surface play a significant role in performance and in the prevention of injuries in football. The proper selection and correct fit of shoes play significant roles in keeping the athlete on the playing field. Players wear different types of football shoes for different positions and utilize certain cleat combinations for different playing surfaces and different weather conditions such as rain and snow.
The three main styles of cleats are high-tops, mid-cuts and low-cuts. Many linemen wear high-tops that extend above the ankle. The extra support helps them with their lateral movement and keeps their feet steady when they are taking on the weight of a block.
Mid-cuts offer more support than low-cut models but allow more ability to maneuver than high-top cleats. Mid-cuts are the most commonly used cleats and are especially popular with “skill position” players such as defensive backs, running backs, wide receivers and quarterbacks. They are the best choice for a youth player looking for a good all-around shoe.
Low-cut cleats sacrifice support for a lighter feel. They are popular with wide receivers and defensive backs, positions that benefit from being able to run fast. Players feel the low-cuts provide extra maneuverability to make quick cuts on the field without the feet being weighted down.
There are two main types of studs or spikes that can go on the soles of the cleats. Most are designed for a specific purpose like playing on grass or turf or a combination of both. Molded cleats are permanently attached to the outsole on the shoe’s bottom. They are usually made of rubber and are generally less expensive than detachable (removable) cleats. Turf shoes usually use molded rubber cleats to give spring and traction on the harder turf surface. Many youth football leagues require players to wear molded cleats, an all-around cleat suitable for most grass fields, and prohibit the use of metal cleats.
Detachable cleats use studs that players can remove and replace, allowing them to change the studs based on field conditions. Detachable studs often require a wrench for removing and adding the studs, which can be made of rubber, hard plastic or metal. On a hard dry field, a player might use a shorter stud. On a wet field, a longer stud would be best.
Detachable cleats require more maintenance and it takes experience to know which type of studs one should wear on different playing surfaces. For this reason, they are usually recommended for older, more experienced players. Replacement studs generally run in 1/2, 3/4, 5/8 and 1 inch sizes. The dilemma players face is that with the better traction provided by the longer studs, there is an increase in the fixation of the foot to the ground surface and consequently, an increase in the risk of injury.
Fixation of the foot through rigid cleating has been shown to be a primary factor in the production of lower extremity injuries, particularly of the knee and ankle. To reduce these injuries, it is recommended to replace the conventional football shoe with synthetic molded soles with a minimum of 15 cleats per shoe, a minimum cleat diameter of 1/2 inch and a maximum cleat length of 3/8 inches.
Finally, the type of playing surface also may be a potential predisposing factor for lower extremity injury. Interestingly, artifical turf was developed in part to help decrease foot fixation. However, a review of the literature shows a number of studies indicating that this type of surface increases the number of lower extremity injuries that lead to time away from the playing field.
One must stress early detection, rehabilitation and reevaluation of lower extremity strength imbalances and deficiencies as key injury prevention measures. There is evidence that 80 percent of all knee injuries occur to the weaker of two legs with as many as 88 percent of injuries occurring to athletes with leg length inequalities. Athletes with poor muscle strength, particularly in the quadriceps, hamstring and gastrocnemius muscles, are more prone to injury due to the lack of support these muscles provide to the surrounding structures of the knee and other joints. It also appears that athletes with tight heel cords may be more susceptible to lower extremity injury.
The lack of a year-round conditioning and rehabilitation program also may be a potential risk factor. A mandatory, year-round, football-specific conditioning and training program should seek to:
• improve muscular and ligament imbalances and weaknesses;
• facilitate coordination and timing;
• improve flexibility, mobility and agility; and
• enhance cardiovascular and endurance capacities.
An incorporated rehabilitative running program should mimic what the football player will be doing on the field.
The running program should stimulate the joints in all planes of movement. When possible, receivers and running backs should carry the football and have someone throw the football to them. Defensive backs and linebackers should do more than half their running backward in order to simulate covering the receiver and their position-specific demands.
Dr. Caselli is a Staff Podiatrist at the VA Hudson Valley Health Care System in Montrose, N.Y. He is also an Adjunct Professor at the New York College of Podiatric Medicine and is a Fellow of the American College of Sports Medicine.
For related articles, see “Essential Tips For Tackling Football Injuries” in the September 2002 issue and “Recognizing And Preventing Dehydration In Athletes” in the December 2004 issue.
Also be sure to check out the archives at www.podiatrytoday.com .
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