ADVERTISEMENT

Foot and Ankle Injuries in Soccer

October 19, 2018 | Surgery
Enrique Feria-Arias, MD ; Karim Boukhemis, MD ; Christopher Kreulen, MD, MS ; Eric Giza, MD
Author and Disclosure Information

Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article.

Dr. Feria-Arias and Dr. Boukhemis are foot & ankle orthopaedic surgery fellows at UC Davis Medical Center, Sacramento, CA. Dr. Kreulen is Assistant Professor of Orthopaedics, Foot and Ankle Service, at University of California Davis, Sacramento, CA. Dr. Giza is Professor and Chief of the Orthopaedic Foot & Ankle Service, at University of California Davis, Sacramento, CA; Sacramento Republic FC Head Team Physician; and Major League Soccer Medical Research Chair.

Address correspondence to: Eric Giza, MD, University of California, Davis, Department of Orthopaedics, 3301 C Street, Suite 1700, Sacramento, CA  95816 (tel, 916-734-6805; email, ericgiza@gmail.com).

Am J Orthop. 2018;47(10). Copyright Frontline Medical Communications Inc. 2018. All rights reserved.

Enrique Feria-Arias, MD Karim Boukhemis, MD Christopher Kreulen, MD, MS Eric Giza, MD . Foot and Ankle Injuries in Soccer. Am J Orthop. October 19, 2018

TAKE-HOME POINTS

  • Soccer injuries of the foot and ankle are becoming more prevalent due to the ever-growing popularity of the sport.
  • Low ankle sprains represent the majority of foot and ankle–related injuries due to soccer and most can be treated non-operatively, with an early mobilization protocol followed by a phased rehabilitation.
  • High ankle sprains are less common than low ankle sprains; however, they require a lengthier rehabilitation and most of the time are treated surgically.
  • Impingement-like syndromes are common among soccer players and can be due to repetitive microtrauma from recurrent ball impact. Most of these syndromes respond favorably to non-operative modalities.
  • Stress fractures of the foot, although less common, often require surgical stabilization in soccer players.

ANTEROMEDIAL ANKLE IMPINGEMENT

Anteromedial ankle impingement is a less common ankle impingement syndrome. It is associated with eversion injuries or following medial malleolar or talar fractures.64,65 Previous injury to the anterior tibiotalar fascicle of the deltoid complex leads to ligament thickening and subsequent impingement in the anteromedial corner of the talus. Adjacent fibrosis and synovitis are common consequences of impingement; however, osteophyte formation and chondral stripping along the anteromedial talus can also be seen. Patients typically complain of pain along the anteromedial joint line that is worse with activity, clicking or popping sensations, and painful, limited dorsiflexion. On examination, impingement can be detected through palpation over the anterior tibiotalar fascicle of the deltoid ligament and eversion or extreme passive dorsiflexion of the foot, all of which will elicit medial ankle tenderness.17,62 Initial treatment consists of rest, physical therapy, and NSAIDs. Refractory cases may be amenable to arthroscopic or open resection of the anterior tibiotalar fascicle with débridement of any adjacent synovitis and scar tissue.62

POSTERIOR ANKLE IMPINGEMENT

Posterior ankle impingement is often referred to as “os trigonum syndrome” since the posterior impingement is frequently associated with a prominent os trigonum. An os trigonum is an accessory ossicle representing the separated posterolateral tubercle of the talus. It is usually asymptomatic. However, in soccer players, pain can occur from impaction between the posterior tibial plafond and the os trigonum, or because of soft tissue compression between the 2 opposing osseous structures. The pain is due to repetitive microtrauma (ankle plantarflexion) or acute forced plantarflexion, which can present as an acute fracture of the os trigonum. Because soccer is a sport requiring both repetitive and extreme plantarflexion, it may predispose players to posterior ankle impingement (Figures 6A, 6B).62,66

Lateral radiograph of an os trigonum

Clinically, it can be very difficult to detect and diagnose because the affected structures lie deep and it can coexist with other disease processes (eg, peroneal tendinopathy, Achilles tendinopathy).62,66 Patients will complain of chronic deep posterior ankle pain that is worse with push-off activities (eg, jumping). On examination, patients will exhibit pain with palpation over the posterolateral process and with the crunch test. Lateral radiograph with the foot in plantar flexion will show the os trigonum impinged between the posterior tibial malleolus and the calcaneal tuberosity. An MRI will demonstrate the os trigonum as well as any associated inflammation and edema, while it can also demonstrate coexisting pathologies.

Initial treatment consists of rest, NSAIDs, and taping to prevent plantar flexion. Ultrasound-guided cortisone injection of the capsule and posterior bursa can be both therapeutic and diagnostic. A posterior injection can be used to temporize the symptoms so that the soccer player can make it through the season.

Surgical excision is saved for refractory cases, and this can be done either through an open posterolateral approach or arthroscopic techniques. Recently, Georgiannos and Bisbinas67 showed in an athletic population that endoscopic excision had both a lower complication rate and a quicker return to sports compared with the traditional open approach. Carreira and colleagues68 conducted a retrospective case series of 20 patients (mostly competitive athletes). They found that posterior ankle arthroscopy to address posterior impingement allowed for the maintenance or restoration of anatomic ROM of the ankle and hindfoot, ability to return to at least the previous level of activity, and improvement in objective assessment of pain relief and a higher level of function parameters.68

Continue to: TENDON PATHOLOGY

ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT