Turf toe syndrome is a sprain of the plantar
capsule of the base joint of the big toe(metatarsophalangeal joint). It is common in playing football on an
artificial surface and is caused by a forceful dorsiflexion of the big toe due
to increased friction between the shoe and the surface.
Symptoms
and diagnosis
The symptoms are pain, tenderness, and
swelling in the base joint of the big toe. It is particularly painful
during push-off in running and passive dorsiflexion of the joint causes pain.
Treatment
Initial treatment includes RICE treatment, anti-inflammatory agents, and relief of weight
bearing. After 2-4 days, weight-bearing can be resumed, but 2-4 weeks of rest
is recommended before return to football. During the rehabilitation phase, the
great toe can be taped to limit dorsiflexion.
Football
toe
Subungual
hematoma is often called “football toe” because it is more
common in football than in other sports. The injury is usually caused either
by jamming of the longest toe against the toe-box or on an opponent’s stepping
on the shoe.
Symptoms,
diagnosis and treatment
Subungual hematoma produces severe pain which
can be eliminated by making a hole through the nail with a red-hot needle or
straightened paper clip.
Morton’s
syndrome
Morton’s syndrome is a local swelling of a
plantar digital nerve, caused by compression of the nerve between the
metatarsal heads. A player
with hypermobile foot with excessive pronation or a depressed anterior arch is
predisposed to this entity.
Symptoms
and diagnosis
The most common symptom is pain on the plantar
aspect of the foot. The pain may radiate into the adjacent toes and is relieved
by rest.
Treatment
Conservative treatment consists of wide-fitting
shoes and arch support with a pad which can spread the metatarsal bones. Surgical excision through a dorsal incision
is very effective.
Ankle
sprain
Ankle sprains are the most common injuries in soccer. They constitute about 20% of
all football injuries and the incidence in senior players is reported to be
between 1.7 and 2x1000h-1 of exposure to soccer.
Most ankle sprains affect the lateral
ligamentous complex and these injuries are caused by inversion and plantar
flexion of the ankle. The anterior talofibular ligament(TFA) is injured
first(70%). In about 20% of cases, there is a combination injury with tear of
the TFA as well as calcaleofibular ligament. In young growing athletes with
strong ligaments and in elderly patients with brittle bones, an
inversion/plantar flexion trauma could cause a bony avulsion at the tip of the
lateral malleolus, whilst the ligaments remain intact. Injuries to the deltoid
ligament on the medial side are uncommon, accounting for less than 10% of all
ankle sprains. The mechanism behind these injuries is pronation and outward
rotation of the foot.
Symptoms
and diagnosis
The diagnostic of an ankle sprain is made by
the presence of swelling and tenderness over the injured ligament. The clinical anterior drawer test is positive
in case of rupture of the TFA, but this test can be difficult to evaluate in
acute injuries with pain and swelling. An X-ray examination is suggested to
exclude fractures and bony avulsions and X-ray with an anterior drawer test
confirms the diagnosis of lateral ligament injury.
Concerning differential diagnosis, a
syndesmosis injury should be suspected in cases with tenderness over the
junction of the tibia na fibula and a widening of the ankle mortise at X-ray.
If left untreated, a syndesmosis injury could later cause lateral subluxation
of the talus which impairs performance in soccer.
Treatment
The
initial treatment of ankle sprains consists of limiting bleeding and swelling
by the use of RICE therapy. The treatment should be immediate and
intensive. A compression bandage suitable for ankle sprains is a
horseshoe-shaped pad around the lateral malleolus(over the three ligaments)
combined with overlaying elastic bandage. The
compression bandage should be used for 3-7 days or until the swelling has
disappeared. The bandage should be kept on over night. The use of crutches is
recommended during this period to minimize loading. As soon as pain subsides,
mobility training including flexion and extension of the ankle joint is
started.
When swelling subsides, the elastic bandage
should be replaced by a supportive tape bandage. The ankle joint should be
taped continuously for 5-6 weeks. To avoid skin problems and loosening of the
tape, retaping each week is recommended. Healing of the ligament takes 6-8
weeks, but with proper taping and rehabilitation, return to soccer can take
place earlier.
If a ligament injury still causes instability
problems 4-6 months after conservative treatment, surgery is indicated. The
results after suture or reconstruction of a ligament injury are favorable. An
ankle sprain may also cause cartilage injuries or osteochondral fractures on
the talus. The symptoms are
pain and tenderness(common on the medial side), swelling and locking.
Arthroscopy or arthrotomy are valuable for diagnosis and treatment.
Achilles
tendon injuries
Usually
caused by trauma(total or partial rupture) or by overuse(Achilles tendinitis or
Achilles bursitis). Two factors predispose to Achilles tendon injuries: a) the
great load that is put on the tendon in athletic activities; and b) the poor
circulation of the tendon.
Concerning the load, the critical limit for tendons is estimated to be about
5000 Nxcm-2.The cross section area of the Achilles tendon is about
2cm2 and since the forces put on the tendon is about 5000- 10000N in
sprinting activities, it is clear that many activities in soccer put a stress
on the Achilles tendon which is close to its critical limit.
Injuries of the Achilles tendon usually occur
at the zone of poor circulation, which
is located 2-6 cm above it’s insertion at calcaneus.
Total
rupture of Achilles tendon
Total ruptures usually occur in degenerated
tendons and are therefore more common in elderly players or in players
previously affected by Achilles tendinitis.
Symptoms
and diagnosis
Typically, the player feels like he has been
kicked on the tendon. The player can usually walk normally, but is unable to
stand on tiptoe. There is a distinct tenderness over the ruptured area and a
gap in the tendon can be felt. Definite diagnosis is made with the Thompson
test. In this test, the calf is squeezed, and if the ankle fails to flex, the
Achilles tendon is ruptured.
Treatment
Treatment of a complete rupture of the Achilles
tendon in an active soccer player should be surgical.
Partial
rupture of the Achilles tendon
Partial ruptures of the Achilles tendon are
common in soccer players and they often become chronic and cause prolonged
problems.
Symptoms
and diagnosis
Usually the player experiences a sharp pain in
the tendon on jumping, sprinting, and other explosive movements. A nodule is
palpable in the tendon, usually 2-6 cm above the os calcis.
Treatment
Conservative
treatment consists of rest, a heel lift, and anti-inflammatory medication. If
conservative treatment fails, the nodules should be exposed and degenerative
areas of the tendon restricted. If conservative treatment fails, the nodules
should be exposed and degenerative areas of the tendon resected. The
rehabilitation period after surgery is usually 4-6 months before soccer can be
resumed.
Achilles tendinitis is the most common
tendonitis seen in soccer players. It is an overuse injury resulting from prolonged repeated loading. Anatomical
malalignments such as flat feet, pes cavus, or muscle tightness of the calf
muscles predispose to this injury.
Symptoms
and diagnosis
The major symptom is pain, which is aggravated
by activity and relieved by rest. The player usually complains of stiffness in the
morning and before and after activity.
Treatment
The treatment consists of rest, heel lift, ice
massage, and anti-inflammatory medication for a couple of weeks. If the player does not rest, the acute
inflammation may turn into a chronic condition where the pseudosheath of the
Achilles tendon becomes fibrotic and stenotic and may require surgical
decompression consisting of removal of the entire pseudosheath.
The retrocalcaneal bursa is located between the
Achilles tendon and os calcaneus. Inflammation and hypertrophy of this bursa is common in soccer players
due to either kicking in the area of pressure from the football shoes. A
prominent posterior tubercle of the os calcis may be an additional cause of the
bursitis.
Symptoms
and diagnosis
The pain and tenderness at palpation are
located at the insertion of the tendon, more distal then the location of an
Achilles tendonitis or a partial rupture.
Treatment
Conservative treatment with ice or injection of
cortisone in the bursa is usually favorable. In chronic cases, surgery is indicated. During the exploration, the
bursa and the bony prominence are removed.
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