Navigating the NFL Injury Report: Foot and Ankle Injuries

Ankle Sprains

Maurkice Pouncey suffers high ankle sprain in 2011 playoffs

The classic (low or lateral) ankle sprain occurs when the foot is flexed inward (inversion injury). These common injuries are treated with boot immobilization and aggressive rehabilitation and rarely result in loss of playing time. Grade 3 injuries with chronic instability or avulsion fractures of the fibula may require surgical fixation and a much longer recovery time.

A high ankle sprain is an injury to the ligamentous structure (syndesmosis) that stabilizes the two bones of the lower leg. It commonly occurs when the foot is forcefully rotated outward away from the lower leg.

(YouTube video of Maurkice Pouncey’s high ankle sprain vs the Jets during the 2011 playoffs.)

Syndesmotic ligament anatomy (image from 3.bp.blogspot.com)

High ankle sprains heal more slowly than low ankle sprains, with Grade 1 injuries usually requiring 1-2 weeks of rehabilitation and Grade 2 sprains often needing 3-4 weeks to heal. Slow healing injuries may take longer. Grade 3 high ankle sprains require surgical fixation of the ligament and are also usually associated with fractures to the fibula. There are reports of return to full activity following surgery in six weeks, with 8-10 weeks a more conservative and realistic estimate in most cases.

Achilles Tendon Rupture

The Achilles tendon is the largest tendon in the body and attaches the calf muscles to the back of the heel. A ruptured Achilles tendon most commonly occurs when a player’s full body weight comes down on a straight leg with the ankle fully flexed. Unlike a patellar tendon tear, it is not uncommon for a healthy Achilles tendon to rupture under stress, but players with chronic irritation and calcification of the tendon are at higher risk of injury.

Surgical reconstruction is recommended for both significant partially torn and completely ruptured tendons. Minimally invasive surgical techniques and aggressive rehabilitation schedules to minimize loss of range of motion have shortened recovery times to six months in many cases. In recent years, many players have recovered to near their previous levels of activity and function, though loss of explosiveness remains a significant concern.

Lisfranc Dislocation / Fracture

The Lisfranc joint is a complex of many joints between the long bones of the foot and the smaller bones between the foot and ankle and includes the Lisfranc ligament, which connects the second metatarsal to one of the smaller bones in the middle of the foot. Injuries in this area include sprains to the ligament, fractures to the bones surrounding the joint and dislocations. The most common mechanism of injury is relatively low impact – another player falls on the back of the foot or heel while the foot is planted and flexed with the toes on the ground.

Lisfranc joint complex (image from aafp.org)

Minor ligament sprains can cause enough displacement in the joint complex to cause significant pain and instability in the middle of the foot. Low grade sprains with very little joint displacement can be treated without surgery, but require immobilization and crutches for at least six weeks. Joint displacements as little as 2 mm are considered to be Grade 3 sprains due to the high likelihood of instability to the joint. Those injuries and/or any associated fractures must be treated surgically.

The severity of the dislocation, location of any associated fractures, presence of articular cartilage damage and possibility of damage to blood supply to the region all affect the success of surgical repair. Outcomes have improved over time, but chronic pain and early arthritis in the joint remain common long term complications. Recovery and rehabilitation after surgery is usually expected to take six months, though some studies are considering whether removing surgical screws sooner may shorten recovery times.

Plantar Fasciitis

The plantar fascia is a tough ligament that supports the arch of the foot and runs from the base of the toes to the heel. Plantar fasciitis is usually an overuse syndrome, with repeated stress along the arch leading to a cycle of inflammation and loss of elasticity in the structure and degenerative changes. The plantar fascia can also rupture with continued stress to an already inflamed area.

Plantar fascia (image from webmd.com)

Immobilization, orthotic shoe inserts, stretching and massage programs and steroid injections may help to limit the pain associated with plantar fasciitis, but prolonged rest and limiting the stress to the ligaments are necessary to resolve the symptoms. If those interventions aren’t successful, surgery to release part of the plantar fascia may be recommended to relieve tension in the ligament. Chronic pain and gait changes remain possible after surgery.

Turf Toe

Turf toe is an injury to the ligamentous capsule that surrounds the joint between the base of the big toe and the long bone of the foot behind. These injuries most commonly occur when the foot is flexed and planted and the first toe is hyperextended, either when planting and changing direction or when another player lands on the foot from behind.

Capsular ligament of the big toe (image from summitmedicalgroup.com)

Because the small area assumes a load many times the weight of the body during football-related activities, even Grade 1 injuries can be difficult to recover from quickly. Taping to support the toe joint, steel insole plates, rest and immobilization are likely treatments, but significant Grade 1 and most Grade 2 injuries can take 2-4 weeks to fully heal. Grade 3 injuries may take 4-6 weeks. Since many players will attempt to play through or return quickly with a toe sprain, the time to full recovery and effectiveness is even longer.

If chronic pain or instability of the toe joint persists, surgery may be recommended. Recovery and rehabilitation usually lasts 3-4 months, though it may be at least six months before a player can return to his pre-injury level of function.

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