Foot and Ankle Awareness in the Athlete

In this current issue of Sports Health, research and treatment interventions for athlete foot and ankle issues are highlighted. I applaud Editor-in-Chief Dr Edward Wojtys and his editorial board for this decision, given the fact that sport-related foot and ankle disorders appear to be on the rise, necessitating the need for heightened awareness from all providers.

In recent National Football League (NFL) research, 60% of injuries recorded occurred to the lower extremity, and nearly half of those were to the foot and ankle. ⁸ In a National Collegiate Athletic Association (NCAA) database review by Hunt et al, ⁴ 33% of all orthopaedic injuries sustained were to the foot and ankle. As a foot and ankle specialist dealing with athletes of multiple ages, I have seen foot and ankle injuries on the rise, and these are frequently a result of overuse/stress-related conditions. However, it is no longer the elite college-aged individual or career athlete being affected. One area of particular concern is the young female athlete, in whom we have seen an upswing in stress fractures of the foot. While this concerning trend is likely to be multifactorial, including relative energy deficiency in sport (aka, the female triad), poorly monitored training regimens, inappropriate footwear, and vitamin D deficiency may all play a role.

As a cochair of the NFL Musculoskeletal Committee and serving with Dr Wojtys for the past 6 years, I have had the privilege of learning how and why foot and ankle injuries occur in the professional football player and have worked to apply this knowledge to other sports. Improved data collection platforms have allowed us to better decipher injury demographics. ⁴ While lower extremity injuries such as turf toe, Lisfranc injury, and high ankle sprains are all multifactorial in origin, there is a common theme: surface-cleat interaction. The player desires traction for the best performance. However, increased traction or friction on certain field surfaces may create excessive torque, leading to rotational injury mechanisms and exceeding the thresholds for the normal ligament. Mack et al ⁷ and others ^2,3 have shown the increased lower extremity injury rate on artificial surfaces as compared with grass. Future challenges will be to work with our industry partners to create innovative cleat designs that allow for proper release under high-torque conditions while also developing synthetic surfaces that better mimic grass.

Our NFL research has also identified concerns with regard to proper shoe wear. This work^5,6 was published previously in Sports Health and remains a factor in the rise in foot and ankle injuries. Our surveys conducted among the NFL teams found an alarming disconnect between the player’s measured foot size and the shoe size actually selected and worn. An improperly fitted shoe places the motion axis of the shoe’s last at a level that does not correlate with the motion segments of the foot. This is most notable in the forefoot and its metatarsophalangeal joints.

Another glaring problem is the lack of adequate width shoes, particularly among our “speed” athletes. We can theorize that too narrow of a shoe will allow the lateral border of the foot to fall over the edge of the last and lead to excessive pressures on the fifth metatarsal, perhaps enhancing the risk of developing a Jones stress fracture. Finally, many shoes have excessive flexibility in the forefoot region. A shoe worn with these conditions may allow the hallux metatarsophalangeal joint to excessively dorsiflex and subsequently surpass the natural integrity of the plantar plate-sesamoid complex leading to a turf toe or Lisfranc injury.

Various testing equipment has been developed within the NFL to assess the safety conditions of the field surface, cleat interaction, shoe mechanics, and even proper fit. However, we need to apply this to all ages and all sports. We all need to do our part in educating the athlete on all the potential factors that may place them at risk of developing a foot and ankle injury. We also need to place more pressure on industry to create a paradigm shift: that the athlete’s shoe/cleat is a form of protective equipment and not apparel. As we move toward creating a safer external environment for our running athletes, we also need to learn more about the intrinsic factors and biomechanics as they relate to the rising number of lower extremity injuries. Much needs to be accomplished in this area, and we are fortunate to have numerous centers and researchers dedicating themselves to this goal.

Six papers^1,9-11,13,14 have been selected for this issue to help focus on sport-related foot and ankle disorders, and many highlight the needed fundamental research and biomechanical analysis. This focus topic begins with an informative outline of the indications for injections in athletes diagnosed with a variety of foot and ankle conditions by Ochoa and colleagues. ¹¹ Further, the discussion of the types of injections available with their efficacy and potential risks is presented. This submission will serve as a useful reference for those providing nonoperative modalities. Most important is that the authors highlight the need for future research in the use of biologics as an injection option.

In the contribution by Martin-Fuentes and colleagues ⁹ from Spain, we get a glimpse of how simple foot posture may or may not have effects on conditioning and kinematics of the lower extremity. This is an example of where our biomechanical research may help to alter and improve an athlete’s training and strengthening methods.

Ankle dorsiflexion and the lack thereof may influence the risk of developing lower extremity injuries but also factor into the recovery process with the potential for compensatory injuries. The paper by Taylor and colleagues ¹³ illustrates the importance ankle dorsiflexion may have in the rehabilitation of the athlete. As motion analysis becomes more available to those managing the rehabilitation, we will be better able to educate the athlete on deficiencies and how to overcome them.

Chronic lateral ankle instability is a very common sequel of the ubiquitous inversion ankle sprain. The practitioner’s ability to objectively test for mechanical instability at both the ankle and subtalar joint level is limited, as noted in the article by Netterstrom-Wedin et al. ¹⁰ Functional instability is typically a result of incomplete rehabilitation, and the article by Wu et al ¹⁴ provides an opportunity to utilize a specific rehabilitation technique to minimize that occurrence.

The last paper ¹ presented within this focus topic is very important, given the increasing number of Achilles tendon ruptures seen across all sectors. Bonanno and associates ¹ in New York illustrate the significant risk in women’s gymnastics. These soft-tissue injuries are no longer relegated to the male enthusiast in the 28- to 48-year-old range. Not only does this article emphasize the risk that the female athlete has to this potentially devastating injury but also the association with single-sport subspecialization and overuse as well as retinoid medications. This is a valuable start to an area that needs advanced research to identify other risk factors and preventive measures.

Outside of the focused topic section of this issue, please give considerable attention to the article on vitamin D and future directions. ¹² Many of our athletes are vitamin D deficient, and those sustaining stress fractures of the lower extremity have a positive correlation between the two.

I wish to thank Dr Wojtys and others at Sports Health for inviting me to share my thoughts and experiences as they relate to the athlete sustaining a significant foot or ankle injury. I sincerely hope that this collection of focused papers will bring heightened awareness to how common and concerning these types of disorders can be and how all of us managing the athlete need to work toward limiting the number and severity of them.

—Robert B. Anderson, MD
Director, Bellin Titletown Sports Medicine and Orthopedics
Associate Team Physician, Green Bay Packers
Green Bay, Wisconsin