Clinical Review

Foot and Ankle Injuries in American Football

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Physicians need to be aware of a variety of foot and ankle injuries that commonly occur in American football, including turf toe, Jones fractures, Lisfranc injuries, syndesmotic and deltoid disruption, and Achilles ruptures. These injuries are often complex and require early individual tailoring of treatment and rehabilitation protocols. Successful management and return to play requires early diagnosis, a thorough work-up, and prompt surgical intervention when warranted with meticulous attention to restoration of normal foot and ankle anatomy. Physicians should have a high suspicion for subtle injuries and variants that can occur via both contact and noncontact mechanisms.



Foot and ankle injuries are common in American football, with injury rates significantly increasing over the past decade.1-5 Epidemiologic studies of collegiate football players have shown an annual incidence of foot and ankle injuries ranging from 9% to 39%,3,6 with as many as 72% of all collegiate players presenting to the National Football League (NFL) Combine with a history of a foot or ankle injury and 13% undergoing surgical treatment.5 Player position influences the rate and type of foot and ankle injury. Offensive and “skill position” players, including linemen, running backs, and wide receivers, are particularly susceptible to foot and ankle injuries due to high levels of force and torque placed on the distal extremity during running, cutting, and tackling. Shoe wear changes, playing field conditions, increasing player size and speed, and improved reporting of injuries are also contributing to increasing injury rates.

The interaction between player cleats and the playing surface is a central issue of foot and ankle injuries in football. Improved traction relates to performance, but increased subsequent torque on the lower extremity is associated with injury. While lateral ankle sprains are the most common foot and ankle injury experienced by football players,7 numerous other injuries can occur, including turf toe, Jones fractures, Lisfranc injuries, syndesmotic disruption, deltoid complex avulsion, and Achilles ruptures. It is important for physicians to be able to recognize, diagnose, and appropriately treat these injuries in players in order to expedite recovery, restore function, and help prevent future injury and long-term sequelae. This review focuses on updated treatment principles, surgical advances, and rehabilitation protocols for common football foot and ankle injuries.

Turf Toe

The term “turf toe” was first used in 1976 to refer to hyperextension injuries and plantar capsule-ligament sprains of the hallux metatarsophalangeal (MTP) joint that can lead to progressive cock-up deformity.8 While these injuries can occur on any surface and disrupt soft tissue balance with functional implications, predisposing factors include increasing playing surface hardness and decreasing shoe stiffness. In a classic scenario, the foot is fixed in equinus as an axial load is placed on the back of the heel, resulting in forced dorsiflexion of the hallux MTP joint.9 As the proximal phalanx extends, the sesamoids are drawn distally and the more dorsal portion of the metatarsal head articular surface bears the majority of the load, causing partial or complete tearing of the plantar plate with or without hallux MTP dislocation. Osteochondral lesions of the MTP joint and subchondral edema of the metatarsal head can occur concurrently as the proximal phalanx impacts or shears across the metatarsal head articular surface.

Clinical examination should focus on hallux swelling, alignment, and flexor hallucis longus (FHL) function along with vertical instability of the hallux MTP joint using a Lachman test. Radiographs should be evaluated for proximal migration of the sesamoids or diastasis (Figures W1A-W1C).

Figures W1A-W1C
Forced hallux MTP dorsiflexion lateral view can help assess the distance from the distal sesamoid to the base of the phalanx. A small fleck of bone pulled off of the proximal phalanx or distal sesamoid may indicate a capsular avulsion or disruption. Live fluoroscopy can be very helpful in diagnosing turf toe, as the physician can assess the trailing motion of the sesamoids with increasing dorsiflexion and evaluate instability in all planes. Magnetic resonance imaging (MRI) is useful for subtle capsular injuries and can also identify osseous and articular damage that may occur and FHL disruption (Figures W2A, W2B).
Figures W2A, W2B
Nonoperative intervention focuses on rest, ice, compression, and elevation (RICE) and nonsteroidal anti-inflammatory drugs (NSAIDs). The hallux is temporarily immobilized in a plantarflexed position using a short leg cast or walking boot with toe spica or turf toe plate with tape for 2 to 3 weeks.

Indications for surgical intervention include loss of push-off strength, gross MTP instability, proximal migration of the sesamoids, and progressive hallux malalignment or clawing after immobilization. Cases can involve one or a combination of the following: (1) large capsular avulsion with unstable MTP joint; (2) diastasis of bipartite sesamoid; (3) diastasis of sesamoid fracture; (4) retraction of sesamoid; (5) traumatic hallux valgus deformity; (6) vertical instability (positive Lachman test); (7) loose body in MTP joint; or (8) chondral injury in MTP joint. The goal of surgery is the restoration of anatomy in order to restore normal function of the hallux MTP joint.

We have found that using dual medial and plantar incisions places less traction on the plantar medial cutaneous nerve, improves lateral exposure, and provides better wound healing. The medial capsulotomy extends from the metatarsal neck to the mid-phalanx to provide complete visualization of the sesamoid complex (Figures 1A-1F).

Figures 1A-1F
The collateral ligaments are often torn away from the metatarsal head during the initial dissection and the plantar plate tear is distal to the sesamoid complex. The soft tissue defect in the plantar complex must be closed distal to the sesamoids followed by advancement of the plantar plate to the proximal phalanx in a distal to proximal fashion and advancement of the medial capsule. The plantar incision is made along the lateral border of hallux MTP-sesamoid complex just lateral to the weight-bearing surface of the hallux and the plantar lateral cutaneous nerve is carefully dissected and retracted out of the way. Sutures are placed in a figure-of-eight fashion through the plantar capsule and plantar plate starting lateral to medial to reduce injury to the nerve. If the tear cannot be primarily repaired due to inadequate healthy tissue, a plantar plate advancement can be performed directly onto the base of the proximal phalanx using drill holes or suture anchors. Proper alignment and motion of the sesamoids should be verified with fluoroscopy and compared to the contralateral hallux (Figures W3A, W3B).
Figures W3A, W3B

It is important to recognize that not all turf toe injuries involve pure hyperextension on artificial playing surfaces. In recent years, we have found an increasing rate of medial variant turf toe injuries in which a forceful valgus stress on the hallux leads to rupture of the medial collateral ligament, medial or plantar-medial capsule, and/or abductor halluces. Medial variant turf toe can lead to progressive hallux valgus and a traumatic bunion with a significant loss of push-off strength and difficulty with cutting maneuvers. Surgical treatment requires a modified McBride bunionectomy with adductor tenotomy and direct repair of the medial soft tissue defect.

Postoperative management is just as important as proper surgical technique for these injuries and involves a delicate balance between protecting the repair and starting early range of motion (ROM). Patients are immobilized non-weight-bearing (NWB) for 5 to 7 days maximum followed immediately with the initiation of passive hallux plantarflexion to keep the sesamoids moving. Active hallux plantarflexion is started at 4 weeks after surgery with active dorsiflexion from 6 to 8 weeks. Patients are transitioned to an accommodative shoe with stiff hallux insert 8 weeks postoperative with continued therapy focusing on hallux ROM. Running is initiated at 12 weeks and return to play (RTP) is typically allowed 4 months after surgery.


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