By Howard Kashefsky, DPM
Soccer is the most popular sport in the world,1 with 265 million male and female players (4% of the world’s population), and the game’s injuries are associated with a whopping estimated annual cost of US $30 billion per year.2 Soccer is the third-most played team sport in the US, behind only basketball and baseball/softball.3 Growth of the game has been steady in the US, rising from 13 million Americans in 2009 to 18 million Americans in 2012; 78% of players are younger than 18 years. In the 1990s, soccer was recognized as the fastest-growing college and high school sport in the US.4
Growth has been highest among young women since the US women’s soccer team won the World Cup in 1991, 1999, and 2015. In the US, 35% of soccer players are women, one of the highest percentages of female participation in the sport in the world. Female participation in US high school soccer has risen by more than 177% since 1990.5
Foot and ankle injuries in soccer
In a study by Oztekin et al of 200 soccer players on natural grass, 66 (33%) reported foot and ankle symptoms.6 The following mechanisms of injury were reported (listed from highest to lowest incidence):
- Direct player-to-player contact (32%)
- Overuse (26%)
- Tripping on the grass (10.5%)
- Landing (7.5%)
- Jumping and jumping/landing (7.5%)
- Tackling (4.5%)
- Being tackled (4.5%)
- Shooting (3%)
- Kicking and kicking/shooting (3%)
- Sprinting (1.5%)
Of all foot and ankle injuries in soccer, ankle sprains are the most common (80%), followed by bruises (9%-49%) and tendon lesions (2%-23%).7 Fractures are rare, accounting for only 1% of all ankle injuries in soccer.7
Soccer players with a history of ankle sprain are 4.9 times more likely to have a recurrence than those with no history.8 Other factors associated with ankle sprains are cavus foot type, ankle instability, joint laxity, reduced lower extremity strength, and anatomic misalignment.9 Approximately 80% of ankle sprains can achieve full recovery; the remaining portion may have chronic instability.9 Physical therapy, including positional training, may help with recovery and prevention.10 Acutely, a period of short-term immobilization along with rest, ice, compression, and elevation as well as nonsteroidal anti-inflammatory drugs (NSAIDs), followed by therapy, is useful in the vast majority of cases.11 However, some cases that remain problematic may require surgery; for example, a direct anatomic ligament repair using a modified Broström-Gould procedure.12
In my experience, magnetic resonance imaging (MRI) and computed tomography may be indicated in addition to x-rays when there is a deeper nonlocalized pain and osteochondral lesions of the talus or other less common injuries of the ankle joint complex are suspected. Some studies suggest these lesions may respond to platelet-rich plasma,13,14 though this topic is controversial. In athletes that do not respond to conservative care for osteochondral lesions, defects of the talus may require repair. Surgical intervention for osteochondral lesions depends on the size and location of the defect.15
Repetitive ankle injuries can lead to arthritis.16 Analysis shows retired professional soccer players are more predisposed to ankle arthritis than the general population.16
Another more insidious injury to the ankle is anterior ankle impingement, which has been reported to affect up to 60% of soccer players.17 It is believed to be related to microtrauma from repetitive ball impact.18 The anterior tibial area may develop swelling and pain related to a bone spur blocking normal range of dorsiflexion motion. Treatment of cases that fail conservative care could include arthroscopic or open debridement to improve ankle dorsiflexion and reduce pain and swelling.
Posterior ankle impingement is associated with pain during ankle movement, particularly in plantar flexion. Possible causes include Achilles or flexor hallucis longus tendinopathies; retrocalcaneal bursitis; os trigonum syndrome; and bone, osteochondral, or neurovascular lesions that involve the Stieda process and fractures.19,20 About 60% can avoid surgery; operative management is typically arthroscopic.
Tendon injuries in soccer
Achilles tendon disorders account for 2.5% of all injuries and 3.8% of layoff times in men’s professional soccer, and the frequency varies considerably from country to country.21 The disorders are most common in older players, and most involve gradual onset (96%) of tendinopathy, with 4% involving acute partial or total ruptures.6 Although there may be disagreement about whether surgical or nonsurgical treatment is the best option, operation appears to be more suitable for athletes due to the faster return to previous activities and the lower rerupture rate.22 Although injury to the Achilles is most common, injuries to the posterior tibial tendon, flexor hallucis longus, and peroneal tendons also have been reported.6
In reviewing conservative midportion Achilles tendinitis management,23 Rowe et al in 2012 reported that evidence was strong for eccentric loading exercises and extracorporeal shockwave therapy, and moderate for splinting/bracing, active rest, low-level laser therapy, and concentric exercises. In-shoe foot orthoses and therapeutic ultrasound were supported by limited evidence. There was conflicting evidence for topical glycerin trinitrate. Taping techniques and soft-tissue mobilization had not yet been examined other than in case studies. Surgery is rarely needed for soccer-related tendinopathy.12
Ankle fractures are the most common (36%) lower leg fractures associated with soccer; next are combined types of fractures of the foot (33%), and fractures isolated to the tibia are the least common (22%).15 Fifth metatarsal fractures are relatively rare in soccer, but have a high rate of healing complications.24 Ekstrand et al recommended that surgical management be strongly considered.24
Plantar fasciitis in soccer
Plantar fasciitis occurs frequently in all running-related sports;25 in my experience soccer is no exception. It is underreported in the soccer injury literature, and in my opinion this is likely because it is self-treated and often self-limiting. Rarely, it becomes chronic and leads to fasciosis and long-term problems.
Some soccer cleat manufacturers have now incorporated ethylene vinyl acetate (EVA) foam into the heel along with other design features to reduce trauma to the soft tissue. In addition to EVA, athletes suffering from plantar fasciitis should wear a soccer cleat with arch support to take stress off the ligament on the bottom of the foot.
Foot orthoses have been established as helpful for plantar fasciitis in the general population.26,27 Some prefabricated foot orthoses include shock-absorbing silicone and have a low-profile carbon clip for fitting into soccer cleats; in my experience this type of design has been widely accepted by trainers and athletes. Labs also can create custom orthotic devices with gel in the heel for soccer cleats; however, the shoes need to be sent to the lab along with the impressions for proper fitting into low-volume soccer cleats. Turnaround time for custom device fabrication is also a consideration, since players will want to return to sport as soon as possible.
My experience has led me to develop a plantar fasciitis kit to be used by both athletes and the general population along with training modifications. In the clinic, I have found successful outcomes often require the use of multiple modalities, and the plantar fasciitis kit reflects that. The kit includes compression, night splints, fasciitis-specific orthoses with cushion in heel, and a trigger point tool. Lee et al demonstrated that combining some of these modalities, such as the night splint and foot orthoses, can lead to better outcomes than foot orthoses alone.28 Of note, I recommend night splint use for just two hours per day in the evening, rather than all night, as most patients do not sleep well while wearing them; in my experience, this recommendation has not had a negative effect on outcomes. Night splint dosage has not been studied, but it may be useful.
The plantar fascia can rupture completely, and this has been reported in soccer players. Such a case was reported in 2016 by Pascoe and Mazzola.29 The athlete had immediate pain rather than gradual onset, which led to a high suspicion of a tear and was later confirmed by MRI as an acute tear of the plantar fascia.
An ounce of prevention
The use of foot orthoses for prevention of overuse injury remains controversial. Some studies show they clearly help, while others do not.30,31 In my personal experience, orthoses can have preventive benefits in some cases, but predicting which athletes will benefit most and determining how best to write a prescription for each individual is currently more of an art than a science.
In a recent systematic review of preventive interventions for Achilles tendinopathy,32 Peters et al found limited evidence to support a long-term intervention including balance training. Shoe adaptations in the form of shock-absorbing insoles could have a preventive effect on Achilles tendinopathy. Hormone replacement therapy seems to reduce the risk for structural Achilles tendon changes in active postmenopausal women. No evidence was found for a positive effect of stretching exercises.
A meta-analysis by Grimm et al of studies on ankle injury prevention programs in soccer players identified a significant reduction in injury risk.33 The interventions utilized included neuromuscular, proprioceptive, strengthening, and stretching exercises.
More research needs to be done to unify the multiple medical fields involved in managing care of soccer players and to develop strategies for preventing foot and ankle injuries in these athletes.
Soccer is a growing sport in the US, especially among young women. Lower extremity specialists need to be familiar with injuries that will occur and the data surrounding these injuries to best diagnose and manage them. With your help, the soccer players you treat will be better able to bend it like Beckham!
Howard Kashefsky, DPM, is the director of podiatry services at UNC Healthcare at the University of North Carolina at Chapel Hill.
- 2006 Big Count: A FIFA Survey. Fifa.com. http://www.fifa.com/mm/document/fifafacts/bcoffsurv/bigcount.statspackage_7024.pdf. Accessed December 12, 2016.
- Wong P, Hong Y. Soccer injury in the lower extremities. Br J Sports Med 2005;39(8):473-482.
- US Census Bureau, Participation in Selected Sports Activities: 2009. Census.gov. https://www2.census.gov/library/publications/2011/compendia/statab/131ed/tables/12s1249.xls. Accessed December 12, 2016.
- Sports in America — soccer. usa.usembassy.de. http://usa.usembassy.de/sports-soccer.htm. Accessed December 12, 2016.
- Levitan P. Watching soccer: a popular U.S. pastime. usa.usembassy.de. http://usa.usembassy.de/etexts/sport/feature_soccer4.htm. Published July 9, 2008. Accessed December 12, 2016.
- Oztekin HH, Boya H, Ozcan O, et al. Foot and ankle injuries and time lost from play in professional soccer players. Foot 2009;19(1):22–28.
- Fong DT, Hong Y, Chan LK, et al. A systematic review on ankle injury and ankle sprain in sports. Sports Med 2007;37(1):73–94.
- Kofotolis ND, Kellis E, Vlachopoulos SP. Ankle sprain injuries and risk factors in amateur soccer players during a 2-year period. Am J Sports Med 2007;35(3):458–466.
- Chan KW, Ding BC, Mroczek KJ. Acute and chronic lateral ankle instability in the athlete. Bull NYU Hosp Jt Dis 2011;69(1):17–26.
- Ergen E, Ulkar B. Proprioception and ankle injuries in soccer. Clin Sports Med 2008;27(1):195-217.
- Kerkhoffs GM, Van Dijk CN. Acute lateral ankle ligament ruptures in the athlete: the role of surgery. Foot Ankle Clin 2013;18(2):215–218.
- Valderrabano V, Barg A, Paul J, et al. Foot and ankle injuries in professional soccer players. Sports Orthop Traumatol 2014;30:98–105.
- Smyth NA, Murawski CD, Haleem AM, et al. Establishing proof of concept: platelet-rich plasma and bone marrow aspirate concentrate may improve cartilage repair following surgical treatment for osteochondral lesions of the talus. World J Orthop 2012;3(7):101–108.
- Hall MP, Band PA, Meislin RJ, et al. Platelet-rich plasma: current concepts and application in sports medicine. J Am Acad Orthop Surg 2009;17(10):602–608.
- Nery C, Raduan F, Baumfeld D. Foot and ankle injuries in professional soccer players: diagnosis, treatment, and expectations. Foot Ankle Clin 2016;21(2):391-403.
- Larsen E, Jensen PK, Jensen PR. Long-term outcome of knee and ankle injuries in elite football. Scand J Med Sci Sports 1999;9(5):285–289.
- Massada JL. Ankle overuse injuries in soccer players. Morphological adaptation of the talus in the anterior impingement. J Sports Med Phys Fitness 1991;31(3):447-451.
- Tol JL, Slim E, van Soest AJ, et al. The relationship of the kicking action in soccer and anterior ankle impingement syndrome. A biomechanical analysis. Am J Sports Med 2002;30(1):45–50.
- Ribbans WJ, Ribbans HA, Cruickshank JA, et al. The management of posterior ankle impingement syndrome in sport: a review. Foot Ankle Surg 2015;21(1):1–10.
- Lopez Valerio V, Seijas R, Alvarez P, et al. Endoscopic repair of posterior ankle impingement syndrome due to os trigonum in soccer players. Foot Ankle Int 2015;36(1):70–74.
- Kannus P, Natri A. Etiology and pathophysiology of tendon ruptures in sports. Scand J Med Sci Sports 1997;7(2):107–112.
- Holm C, Kjaer M, Eliasson P. Achilles tendon rupture— treatment and complications: a systematic review. Scand J Med Sci Sports 2015;25(1):e1–e10.
- Rowe V, Hemmings S, Barton C, et al. Conservative management of midportion Achilles tendinopathy: a mixed methods study, integrating systematic review and clinical reasoning. Sports Med 2012;42(11):941-967.
- Ekstrand J, van Dijk CN. Fifth metatarsal fractures among male professional footballers: a potential career-ending disease. Br J Sports Med 2013;47(12):754-758.
- Lopes AD, Hespanhol Junior LC, Yeung SS, Costa LO. What are the main running-related musculoskeletal injuries? A systematic review. Sports Med 2012;42(10):891-905.
- McPoil TG, Martin RL, Cornwall MW, et al. Heel pain-plantar fasciitis: clinical practice guidelines linked to the international classification of function, disability, and health from the orthopaedic section of the American Physical Therapy Association. J Orthop Sports Phys Ther 2008;38(4):A1-A18.
- Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heel pain: a clinical practice guideline – revision 2010. J Foot Ankle Surg 2010;49(3 Suppl):S1-S19.
- Lee WC, Wong WY, Kung E, Leung AK. Effectiveness of adjustable dorsiflexion night splint in combination with accommodative foot orthosis on plantar fasciitis. J Rehabil Res Dev 2012;49(10):1557-1564.
- Pascoe SC, Mazzola TJ. Acute medial plantar fascia tear. J Orthop Sports Phys Ther 2016;46(6):495.
- Mattila VM, Sillanpää PJ, Salo T, et al. Can orthotic insoles prevent lower limb overuse injuries? A randomized-controlled trial of 228 subjects. Scand J Med Sci Sports 2011;21(6):804-808.
- Baxter ML, Baycroft C, Baxter GD. Lower limb injuries in soldiers: feasibility of reduction through implementation of a novel orthotic screening protocol. Mil Med 2011;176(3):291-296.
- Peters JA, Zwerver J, Diercks RL, et al. Preventive interventions for tendinopathy: a systematic review. J Sci Med Sport 2016;19(3):205-211.
- Grimm NL, Jacobs JC Jr, Kim J, et al. Ankle injury prevention programs for soccer athletes are protective: a level-I meta-analysis. J Bone Joint Surg Am 2016;98(17):1436-1443.