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Sports Medicine

Practical Insights On Treating Common Soccer Injuries

Soccer is the one of the most popular sports in the world and the physical demands of the sport can lead to a myriad of injuries. Studies have shown that soccer has a high injury rate with most of these injuries occurring in the lower extremity, especially the ankle, the site of 80 percent of all soccer injuries.1–6

Youth and high school soccer have exploded in popularity over the last 25 to 30 years, and there has been a greater participation of women and girls during that time frame. Studies have shown that female players have an overall higher injury rate in comparison to males in competition and training.4 Professional players tend to have a higher injury rate than adolescent players but this is likely due to the intensity of competition. Due to these injuries, there are substantial medical costs and lost time.7

As podiatrists, it is imperative to know common soccer injuries and treatment regimens so the athlete can return to the field as soon as possible. Below are some common soccer injuries but this is not meant to be an all-inclusive list.  

How To Treat Friction Blisters

Maybe the most common foot injury in all of sports, not just soccer, is the friction blister. Blisters can lead to pain and infection, resulting in lost time.  

While the pathomechanics of blister formation are well documented, the prevention and treatment of blisters are not. Antiperspirants, lubricating agents, powders, moleskin, taping, tincture of benzoin and antibiotic ointment are treatment options, but they all have mixed results. Clinicians should drain blisters that have fluid and leave the roof of the blister intact. One can soak blisters in diluted betadine and protect the skin with a commercial skin lubricant to prevent further damage.

Cortese and colleagues studied various methods of treatment for blisters.8 Their recommendation was to leave the roof of the blister intact and perform a single drainage not earlier than 24 hours but no later than 72 hours after injury, or drain the blister three times within the first 24 hours. The authors noted this approach resulted in less pain.    

Often, the blister will refill following aspiration so I advise repeating the aspiration within six to eight hours followed by a compression dressing. Research does not support antibiotic ointment but physicians often use it.
Other options to consider are insole materials and socks. Closed cell Neoprene or Poron and Plastzote are beneficial because of the low coefficient of friction. Herring and Richie studied sock fiber composition and found that fewer blisters formed in acrylic fiber socks in comparison to cotton socks.9 There are multiple options available when treating blisters and a limited amount of evidence to support those options. However, as physicians, we all have our way of treating blisters we see in athletes.  

Key Insights On Treating Turf Toe

Turf toe is considered a sprain of the first metatarsophalangeal joint (MPJ) as a result of a hyperextension injury with disruption to the plantar structures of the first MPJ. The plantar capsule and ligaments are sprained or torn, and dorsal dislocation of the hallux can occur with complete tearing of the plantar structures.   

Thoroughly evaluate the anatomical structures of the first MPJ. Radiographs should include the contralateral foot to evaluate for proximal retraction of the sesamoids, which would indicate a plantar plate tear. Obtain a raised lateral view to rule out any type of dorsal fracture of the joint. Magnetic resonance imaging (MRI) is in widespread use and will help identify any soft tissue damage or articular injury.

Baxter developed a grading system algorithm to aid in treatment and return to play.10 Grade I injury consists of a sprain or attenuation of the plantar capsular ligament complex from which the athlete is able to return to play as tolerated. Initial treatment should consist of rest, ice, compression and elevation (RICE). Splint the toe in a plantarflexed position. Limitation of dorsiflexion is critical and patients can achieve this with taping, steel or graphite plates. Grade II injury is a partial rupture of the plantar soft tissue structures of the first MPJ. This injury requires about two weeks to recover and may require a walking boot. Grade III injury is a complete tear of the plantar structures that requires about 10 to 16 weeks of recovery time. Grade III injuries usually require boot or cast immobilization, or surgery.

Surgery is rarely needed unless there is complete tearing of the plantar plate, arthritic changes or bone fragments that one needs to remove.

What You Should Know About Calcaneal Apophysitis In Soccer Players

Calcaneal apophysitis, or Sever’s disease, is the most common injury in 8- to 14-year-old soccer players.11 Calcaneal apophysitis is inflammation of the apophysis due to the repetitive pull of the Achilles tendon. The pain can persist for weeks or months because the family and/or coach doesn’t recognize the condition, and does not seek medical treatment. In some instances, the athlete may miss playing time because of the lack of timely treatment. Treatment options include rest, icing, anti-inflammatories, heel lifts, heel cushions, stretching, immobilization, taping and orthotics.

James and coworkers showed that kids with calcaneal apophysitis have a higher body mass index, increased weight, increased height, and more ankle joint dorsiflexion in comparison to normative data.12 Often one can make a custom foot orthotic to alleviate the heel pain. Modifications to the orthotic such as a deep heel cup and increased heel cushioning can be options.   

Evidence now exists that ethylene vinyl acetate (EVA) heel lifts, not cushions or gel pads, are a more effective treatment then a prefab orthotic.13    

Treating Soccer-Related Nail Pathology

Subungual hematomas and ingrown nails are among the most common injuries I see in professional and collegiate soccer players, especially in preseason training. New soccer boots and the snug fit of these boots are the culprits of these conditions.

In private practice, most would avulse the nail with subungual hematoma formation. However, that is rarely the case with collegiate and professional soccer players. The preferable treatment is draining the hematoma, usually with an 18 gauge needle, heated paperclip or electrocautery. A silicone toe cap can help pad and protect the toe to prevent any further irritation. At higher levels of play, avulsing the nail leads to a temporary increase in tenderness with training. Players prefer to keep the nail until a new one grows back but in some situations, the pressure, pain, and/or infection makes avulsion unavoidable. If new nail growth is lifting off the damaged nail, then one can remove the damaged nail plate or trim it back.

Following the loss of a nail, the athlete can be predisposed to ingrown nails. One would typically manage ingrown nails and paronychias with slanting back the nail border or avulsion. It is rare to perform a matrixectomy as long as the condition is manageable until the end of the season.

Dr. Yakel is in private practice in Boulder, Colo. He is the Immediate Past President of the American Academy of Podiatric Sports Medicine and the team podiatrist for the Colorado Rapids of Major League Soccer.

References

1.     Keller CS, Noyes FR, Buncher CR. The medical aspects of soccer injury epidemiology. Am J Sports Med. 1987; 15(3):230–237.
2.     Elias SR. Ten-year trend in USA Cup soccer injuries: 1988–1997. Med Sci Sports Exerc. 2001;33(3):359–67.
3.     Hawkins RD, Fuller CW. An examination of the frequency and severity of injuries and incidents at three levels of professional football. Br J Sports Med. 1998;32(4):326–32.
4.     Hawkins RD, Fuller CW. A prospective epidemiological study of injuries in four English professional football clubs. Br J Sports Med. 1999;33(3):196–203
5.     Hawkins RD, Hulse MA, Wilkinson C, et al. The association football medical research programme: an audit of injuries in professional football. Br J Sports Med. 2001;35(1):43–7.
6.     Giza E, Fuller C, Junge A, et al. Mechanisms of foot and ankle injuries in soccer. Am J Sports Med. 2003; 31(4):550-554.
7.     Wong P, Hong Y. Soccer injury in the lower extremities. Br J Sports Med. 2005; 39(8):473-482.
8.     Cortese TA, Fukuyama K, Epstein W, et al. Treatment of friction blisters. An experimental study. Arch Dermatol. 1968; 97(6):717–21.
9.     Herring KM, Richie DH. Friction blisters and sock fiber composition. A double-blind study. J Am Podiatr Med Asoc. 1990; 80(2):63-71.
10.     Anderson RB, Shawen SB. MTP, metatarsophalangeal toe disorders. In Porter DA, Schlon, et al (eds.) Baxter’s The Foot and Ankle in Sport. Elsevier Health Sciences, Philadelphia, 2007, pp. 411-433.
11.     Wiegerinck JI, Ynetma C, Brouwer HJ, Struijs PA. Incidence of calcaneal apophysitis in the general population. Eur J Pediatric. 2014; 173(5):677-679.
12.     James AM, Williams CM, Luscombe M, et al. factors associated with pain severity in children with calcaneal apophysitis. Pediatr. 2015; 167(2):455-459.
13.     James AM. Effectiveness of footwear and foot orthoses for calcaneal apophysitis: a 12 month factorial randomized trial. Br J Sports Med. 2016; 50(20):1268-1275.

Sports Medicine
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By Jamie Yakel, DPM
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