Doctor of Medicine, specialist in the Japanese Society of Rehabilitation Medicine, specialist in the Japanese Society of Orthopaedic Surgery, specialist in the Japanese Society of Rheumatology, staff to strengthen JOC, and sports physician certified by the Japan Sports Association
Footballer's ankle is a sports disorder resulting from forced ankle plantar dorsiflexion.
Footballer's ankle is a disorder of the ankle that are familiar in Europe and the United States among football players. It is also called ankle impingement syndrome, collisional exostosis, etc. Plantar dorsiflexion of the ankle joint is forced by kicking in football or jumping in basketball. It causes impingement of the ankle joint and results in this sports disorder. (Fig. 1).
* Impingement = caking
Figure 1. Osteophytes on the anterior aspect of the tibial lower end and dorsal aspect of the talus and calcaneus.
Cause and mechanism of onset
The anterior joint capsule is hyperextended by plantar flexion forces on the ankle joint, such as kicking in soccer. In the rear, the bones are damaged by striking on each other. On the other hand, when a person steps on a jump landing, dorsiflexion is forced with impingement on the anterior bone, and the posterior joint capsule is injured by hyperextension. Collisions between bones can damage bone and cartilage (Fig. 2), and osteophytes can form as a repair mechanism for this damage. Athletes who experienced ankle sprains several times become more ankle unstable, resulting in osteophyte formation, joint capsule synovial proliferation, and worsening of pain and other symptoms. In advanced cases, osteophytes may cause fracture, become loose in the joint, or become impinged which cause severe pain.
Figure 2. X-ray (arrow indicates an osteophyte).
Spontaneous pain, tenderness, pain during exercise, and palpation of osteophytes at the ankle joint during kicking or jumping, and, as it progresses, limited range of motion at the ankle joint. The presence of osteophytes on the anterior aspect of the joint may limit dorsiflexion, and osteophytes on the posterior aspect may limit plantar flexion.
The X-ray image in Fig. 2 is a typical image of osteophyte formation in the anterior aspect of the lower end of the tibia, the anterior aspect and neck of the talus, and the posterior aspect of the talus. When a collision is caused by varus or valgus stress of the ankle, osteophytes form on the medial and lateral malleoli and talus. Three-dimensional CT (Fig. 3) is more useful for locating and sizing osteophytes.
Figure 3. Three-dimensional CT image.
Football and rugby with kicking exercises that place a high burden on the ankle, instrumental exercises that allow plantar dorsiflexion of the ankle to be forced with jump landing, classic ballet, basketball, and volleyball are common sports.
Treatment and rehabilitation
In the acute phase, physical therapy, such as local rest, icing, and sometimes apply hot packs, ultrasound, and low frequency therapy are used to treat pain and swelling. Taping and braces to limit joint mobility may also be helpful. When pain is severe, hyaluronan and corticosteroid injections, as for osteoarthritis, are given (but often avoided). If symptoms do not improve with conservative treatment or if a piece of bone is loose, the osteophytes may be surgically removed. Initial rehabilitation begins with non-weight-bearing range-of-motion exercises of the ankle. Next, the patient exercises on the ankle with a light load with a tube and gradually increases the load to aerobics and pool walking.
Photo: Rehabilitation in the initial stage is followed by exercise of the ankle joint with a light load with a tube, and the load is gradually increased.
Head coach of Shonan Bellmares Sports Club Triathlon Team, Head coach of Triathlon Team of Nippon Sport Science University, and Chairman of the Japan Triathlon Union Multi-sports Committee
Footballer's ankle is a disorder in which the ankle joint is forced to perform plantar flexion and dorsiflexion, such as a strong kick to the ball or a reaction from landing, resulting in collisions between the bones, which can cause bone spurs, cartilage damage, pain, decreased range of motion of the ankle, and weakness of the fibular muscles.
Low ankle flexibility is associated with a high risk, so stretching is important. Incomplete treatment of an ankle sprain or instability of the ankle due to repeated ankle sprains may increase stress in the joint. Please take measure of prevention to support instability of ankle joint with ankle supports or taping.
On-site evaluation and first aid
If the ankle is repeatedly swollen and painful, and range of motion is limited, immediate seeking for sports doctor is recommended.
Pain and swelling may limit the ankle's range of motion. Improved range of motion (increased flexibility) is also necessary to prevent recurrence. Dorsiflexion (lifting the toes upward) and plantar flexion (lowering the toes) are performed without weight-bearing. With the consult of doctor or trainer, patients gradually increase the load and apply resistance with a tube or hand.
In addition to plantar flexion and dorsiflexion movements, the muscles that can respond to transverse and twisting movements need to be exercised. The fibula muscles are the muscles that lie outside the lower leg and cause the ankle to pronate (raise the little toe) and are critical for stabilizing the ankle. Some devices, such as those used for manual resistance or tubing, are given in a painless range, and the stress is gradually increased while checking for low-intensity pain.
Photo 1: Muscle training using manual resistance
Photo 2: Training using tubes (Turing inward)
In addition to training the fibula muscle group, training in various directions, such as plantar flexion, dorsiflexion, inversion (moving the toe inward and the little toe down while plantar flexing), and eversion (moving the toe outward while dorsiflexing and raising the little toe side with the toe upward) enhances stability (Photo 1: manual resistance training, turning inward and outward). If a tube is used, the strength of the tube varies depending on the type of tube and the degree of pull. So, the load is gradually increased, starting with the least intense one (Photos 2 and 3: tube exercises, turning in and out).
Photo 3: Training using tubes (Turing outward)
Balance disk and a balance board
To stabilize the ankle, the person is trained using a balance board or a balance disk is recommended. The goal is to move the ankle as smoothly and freely as possible to draw a circle, such as by plantar flexion, dorsiflexion, inversion, and eversion. Initially, the person should sit in a position that does not require weight-bearing and force the balance disk to strike (Photo 4: Balance Disk Sitting), and as the patient recovers, the other foot should be placed on the floor to adjust the weight on the foot (Photo 5: Standing). Ultimately, the person should stand stably on one leg.
Photo 4: Exercise using balance disk (sitting position)
Exercise with balance disk (standing)