Keys To Diagnosing And Treating Common Football Injuries

Lower extremity injuries are more numerous and disabling than ever in football players. Accordingly, these authors detail their evaluation and rehabilitation protocols for addressing plantar fasciitis, turf toe and Achilles tendonitis so physicians can get players back on the field quickly and safely.

American football is a high-impact sport with an increased potential of injuries. According to many recent studies and the NFL’s official injury surveillance system reports, football injuries have steadily increased in numbers and severity over the years.^1,2 For example, total annual NFL injuries have increased from about 2,500 to 4,500 between the 2004 and 2011 seasons.¹ While statistics demonstrate how violent football has become at almost every position and skill level, the statistics also suggest that despite extensive research and current advances in medical treatments, effective long-term solutions remain elusive.  

Accordingly, let us take a closer look at the diagnostic approach and treatment plans for three of the most common lower extremity injuries/conditions in football: Achilles tendonitis, plantar fasciitis and turf toe. The conventional perception is that these injuries are due to individual factors such as strength imbalance, flexibility imbalance, age, playing surface, shoe type, intensity of the activity and previous injuries. However, addressing these factors provides only treatment of symptoms. Re-injury is likely and inevitable as long as the athlete continues to participate in sports.

The aforementioned injuries and conditions are not unique to football. As a matter of fact, they affect athletes in all sports in which running, abrupt change of direction and sudden stops are involved. Similar to running, running technique work is virtually absent from the training process in football. Furthermore, the lack of a consensus on clearly defined standards in running technique makes it difficult to properly consider running gait deficiencies and idiosyncrasies during evaluation and treatment processes. It also makes preventing those injuries difficult.³ While more evidence in regard to specifics and outcomes of altering running technique emerges, we already know that altering running technique may help treat and prevent running injuries. Therefore, it warrants consideration in clinical practice.^4,5

To overcome the persistence and the growing numbers of these injuries, we need a better understanding of their cause. We will attempt to incorporate conventional thought and treatment with a progressive approach to rehabilitation and prevention that involve alterations of running technique based on the Pose Method.⁶

When Football Players Develop Plantar Fasciitis
Plantar fasciitis and plantar fascia tears were in the limelight last season with injuries to two great NFL quarterbacks, Peyton Manning and Drew Brees. Plantar fascia injuries are a prevalent problem in all sports with little consensus on the most common predisposition to injury or best treatment protocol. Plantar fascia tears are the fourth most common injury of the foot and ankle.⁷ Ten percent of all running injuries involve one or more components of plantar fasciitis, and account for approximately 8 to 10 percent of all visits to a sports medicine clinic.⁷

Historically, the literature attributes plantar fasciitis to faulty biomechanics such as excessive pronation, structural deformities such as forefoot varus, forefoot supinatus, flexible and plantarflexed first rays, and forefoot valgus. Overpronation contributes to excessive foot mobility, which can increase the level of stresses one applies to musculofascial and soft tissue throughout plantar fascia elongation. There is some thought that it is not pure excess pronation that occurs in athletes who develop plantar fasciitis but planal dominance of abnormal pronation.⁸

The transverse, planal dominant, pronated foot seems to be the most problematic. The lead author has seen this in his own athletes maybe because this plane of deformity is harder to control with orthotic devices. Difficulties result when joints of the foot are continually functioning beyond a normal range of motion.⁹ This can lead to greater stresses along the medial joint capsules and ligamentous structures. The posterior tibialis muscle can abnormally lengthen as well and fatigues easily. These stresses can lead to pain and discomfort.8 Plantar fasciitis results from the duration of the abnormal motion, not merely the motion itself.¹⁰

We, as clinicians, have also seen athletes with high arch foot types develop plantar fasciitis and partial tears. The traditional theory is that a high arched foot lacks the mobility needed to assist in absorbing ground reaction forces. Consequently, for athletes who heel strike when running, the heel’s inability to dissipate the forces from heel strike to midstance increases the load applied to the plantar fascia, much like the stretch of a bowstring.¹⁰ In addition, this inherently arched foot has major stressors at the heel and first and fifth metatarsal heads.

Thordarson found the posterior tibial tendon provided the most significant dynamic arch support during the stance phase of gait.¹¹ Weakness of the posterior tibial tendon caused by excessive pronation can also cause plantar fascia elongation. When this action occurs, there is a subsequent overuse of the muscles that help with foot supination, such as the flexor hallucis longus, flexor digitorum longus, peroneus longus and the Achilles.¹² Other problem areas along the kinetic chain that can contribute to plantar fasciitis developing in an athlete are proximal muscle weakness in the gluteus medius, gluteus minimus, tensor fascia lata or quadriceps.

Facilitating A Smoother Rehab For Athletes With Plantar Fasciitis
Treatment and prevention of the plantar fascia injury are not easy tasks because of the plantar fascia’s anatomical location. The plantar fascia is at the cross section of all the forces acting upon the body and is involved in practically any movement of the body. This injury happens during a very specific part of walking or running gait. Accordingly, altering the gait may help alleviate pain and consequently prevent recurrence.

Soft tissue massage and physical therapy are helpful in this process. Due to the nature of this, athletes must eliminate all efforts to push off.¹³ Following the Pose Method framework, have the patient replace push off by cue to simply pull the foot up in order to change support to move forward or in any direction.¹⁴

What You Should Know About Turf Toe
Bowers and Martin introduced the term “turf toe” into the literature in 1976 to include soft tissue hyperextension injuries in athletes.¹⁵ Although we have grouped these injuries under the general heading of turf toe, they represent a number of different injuries from mild to severe around all the structures of the first metatarsophalangeal joint (MPJ).

The incidence of turf toe injuries is difficult to quantify.¹⁶ However, turf toe injuries rank third behind knee and ankle injuries at major universities.¹⁷ While researchers coined the term turf toe with the advent of artificial turf, these injuries do not solely occur on artificial turf.¹⁶ In one study involving the University of Arkansas football team, ankle injuries were more prevalent than first MPJ injuries. However, the first MPJ injuries were more severe, accounting for a disproportionate number of missed practices.¹⁸

The most common mechanism of turf toe injury is usually pure hyperextension of the plantar capsule of the first MPJ.¹⁸ To diagnose the structures involved, a knowledge of the functional requirements of the great toe during athletics is necessary. As an athlete rises on the ball of the foot to initiate activities such as jumping, blocking or running, the hallux dorsiflexes at the MPJ upward of 100 degrees. As the proximal phalanx extends, the sesamoids move distally and the articular surface of the dorsal aspect of the metatarsal head bears most of the load. In the progression of forward motion at the first MPJ, the plantar complex attenuates or ruptures, leading to unrestricted dorsiflexion at the joint. This can lead anywhere from partial tearing of the plantar structures to frank dislocation.

In addition to pure hyperextension injury, combined mechanisms occur and depend on the position of the first MPJ and the associated forces applied to the hallux at the time of injury. An injury to the medial plantar structures caused by a valgus directed force is more common than injury to the plantar lateral structures caused by varus directed forces.^19,20 The turf toe type injuries can increase in severity in the presence of excessive foot pronation because of the hypermobility and the lack of stability when the foot hits the ground, thereby allowing a further amount of abnormal dorsiflexion to occur at the first MPJ.

A Guide To The Etiology And Classification Of Turf Toe
We generally accept that the two most common etiologic factors of first MPJ turf toe-type injuries are the playing surface and footwear flexibility. It is likely the athlete at the greatest risk for sustaining injury is the one who participates in cutting or pivoting with lightweight flexible cleats on synthetic turf or hard playing surfaces.¹⁶

Researchers have classified first MPJ acute injuries into three general categories.²⁰ In evaluating these injuries, the clinician must keep in mind there are many variations to the injury. A comprehensive and accurate history is always critical. On-field observations are the most helpful. Reviewing game tape video will provide keys to the real mechanism of injury that occurred. Hopefully, this will be available to you to improve your assessment.

In the actual examination, one should note the presence of ecchymosis and edema, paying attention to the location. Perform palpation of the joint surfaces of the first MPJ. Assess the comparative joint range of motion bilaterally. Assess abnormalities such as a mechanical block from interposed soft tissue entrapment, hypermobility resulting from a plantar plate or complete capsular tear as well as joint instability.¹⁶ Perform varus and valgus stress testing as well as the Lachman test (dorsoplantar drawer test) and compare the test results to the uninjured side. This can help you assess the plantar capsular ligament complex. Resistance examination of the first MPJ can help you evaluate long flexor and long extensor strengths.

Pertinent Treatment Insights On Turf Toe
When treating turf toe, first evaluate the patient’s foot structure as well as shoe and cleat wear, and then make the proper adjustments. One can work with the athlete to improve Achilles, calf and peroneal flexibility, if necessary, in order to increase dorsiflexion through stretching, foam roll and the Graston Technique^®. If the condition is chronic, use the Graston technique and joint mobilization to break up joint adhesions and improve range of motion in the ankle and toe joints.

Intrinsic muscle exercise and foot and toe exercises can help improve function. Exercises include picking up marbles with the toes, toe crunches and towel curls. Control the pain and inflammation with deep icing of the joint along with compression and electrical stimulation. For athletic activity, a “turf toe” tape job can help with function and decrease the chances of irritation.

Understanding The Potential Contributing Factors For Achilles Tendinitis
Achilles tendinitis is a chronic inflammatory condition that can be a major cause of pain and disability.^21,22 Between 7 and 9 percent of all professional athletes in sports that require running or jumping get a diagnosis of Achilles tendinopathy.²¹

Immediately after the foot strikes the ground, the foot rolls into pronation and the knee begins to flex, causing obligatory internal rotatory forces to the tibia.^23,24 As the body passes over the foot during midstance, the foot rolls into supination and the knee begins to extend in preparation for takeoff, causing external rotatory forces to the tibia. In individuals who overpronate, the foot is still pronating after knee extension has begun. This will result in the external tibial rotation generated by knee extension conflicting with the exaggerated internal rotation produced by prolonged pronation. The motion of the hindfoot going from a supinated to a pronated position and then back during the running gait cycle creates a “whipping” action on the Achilles tendon. This creates shear forces across the Achilles tendon, placing particularly high eccentric stresses on the medial side of the tendon.^24,25

Other factors to consider are muscle tightness and weakness, muscle imbalance and leg length discrepancy. Tight triceps surae and hamstring muscle groups may cause compensatory motions at the ankle that may cause tensile forces to not be absorbed or disturbed appropriately.²⁵ Leg length discrepancy alters normal gait patterns and changes the directional load of stress on the tendon. Muscle weakness or imbalance will prevent successful force distribution and may require excessive forces to be dissipated by the Achilles tendon. Extrinsic risk factors, outside of skeletal anatomy, primarily deal with errors in individual training including a sudden increase in training mileage or intensity, a change of terrain, an increase in interval training or a solitary, intense run.^24,25

Key Pointers On Physical Rehabilitation For The Achilles
One should evaluate the hamstring and calf musculature, or recommend evaluation to determine any imbalances and weaknesses. When these imbalances and weaknesses are combined with technical flaws during movement, this causes overload on the Achilles. Utilizing strength exercises and technique drills, a physical therapist can help address hamstring and calf muscle imbalances and weaknesses that may contribute to the tendonitis. The physical therapist can monitor the load and intensity, and make adjustments based on the player’s progress.²⁶ Hip strength exercises are also necessary in order to provide a comprehensive treatment program.

In Conclusion
Treating sports injuries is complicated and time consuming, making preventive strategies and activities essential. The advancement of sports injury prevention will require moving forward to an updated paradigm.^27,28 This will entail an increased awareness of the necessity to expand the diagnostic, treatment and prevention course of action to include biomechanical evaluation, alteration of technique, and advanced movement skill in addition to the medical evaluation.²⁹

Dr. Cohen is the podiatric consultant to the Philadelphia Eagles and Philadelphia 76ers. He is also a consultant to athletic training staff at Temple University, Princeton University, and Drexel University. Dr. Cohen is a Fellow of the American College of Foot and Ankle Surgeons, and is a board-certified foot and ankle surgeon. He is in private practice in Ridley Park, Pa., and Cherry Hill, N.J.

Dr. Romanov is a two-time Olympic coach and the developer of the aforementioned Pose Method, which has been implemented by the U.S. Army, CrossFit and a growing number of physical therapists. He is the founder of the Romanov Academy of Sports Science.

Mr. Tonucci holds a bachelor’s degree in athletic training, is a Certified Strength and Conditioning Specialist, and the Head Athletic Trainer for Dr. Lee S. Cohen and Associates.

Mr. Pyle holds a bachelor’s degree in exercise science, is a Certified Strength and Conditioning Specialist, and is a Pose Method Certified Running Technique Specialist.  

References  

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For further reading, see “Addressing Heel Pain In Football Players” in the November 2015 issue of Podiatry Today, “How To Treat Turf Toe Injuries” in the September 2008 issue or “Pearls On Treating Plantar Fasciitis In Athletes” in the August 2014 issue.

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