Prevention of Ankle Injuries in Soccer Players, from Sheddon physiotherapists in Oakville and Burlington

Soccer requires a lot of sudden stops, cutting, jumping, and landing movements, which have all been shown to increase the risk of lower extremity injuries, especially to the ankle. Roughly 35% of all soccer injuries occur in the ankle, with an average time lost from play of about 48 days. With the high prevalence and long recovery time associated with ankle injuries, identifying modifiable risk factors and prevention strategies is key to keeping athletes healthy on the field.

Note: Sheddon’s physiotherapists from the Oakville and Burlington Physio Clinics are prepared and determined to help you get back to the sport you like.

Thought should also be given to preventing ankle injuries in women’s soccer, as women are physically and physiologically different from men. Although the mechanism of injury might be similar for female and male soccer athletes, there could be differences in the risk factors and prevention strategies.

The success of the national women’s soccer team in qualifying for the 2023 FIFA Women’s World Cup will no doubt encourage more women and girls to play soccer, despite the negative impact the last few years had on the country’s grassroots sport.

A 2022 report by the Canadian Centre for Ethics in Sport states, “Girls’ participation in sport also enhances body image and self-esteem and is associated with higher overall quality of life compared with non-athletes.” There is thus an increased chance that more girls and women will experience ankle injuries while playing a sport and specifically soccer.

Mechanism of Injury

Roughly 50% of soccer related ankle injuries occur during contact with another player. Other common mechanisms include:

• Overuse;
• Tripping on grass;
• Jumping, twisting and landing;
• Tackling;
• Shooting/kicking.

Common Ankle Injuries

The most common ankle injuries experienced by soccer athletes are ligament sprains (80%), followed by overuse impingement syndromes, tendonitis (achilles, peroneals, posterior tibial tendon), and though rarely, soccer players will experience fractures or osteochondral lesions.

Ligament Sprains
Ankle sprains account for 80% of all soccer athlete injuries, and these athletes are 5x more likely to sustain a recurrent ankle injury upon return to soccer. Initial treatment following a sprain will involve modalities, manual therapy, and rest. However, functional treatment is key for long term success, focusing on strengthening, balance, and proprioception required for return to sport.

Research shows that across all National Collegiate Athletic Association (NCAA) women’s sports, soccer has the highest overall injury rate during competition and the highest ankle sprain rate. Lateral ankle sprain (LAS) is the most reported injury resulting in activity loss, and time loss, with the added concern of recurrent injury.

There are three identified degrees of ankle sprains since it accounts for most of the injuries in soccer players.

• 1st Degree
  Involves minimal swelling, point tenderness and there is no ligament laxity. An injured soccer player has no limp or difficulty hopping and generally recovers in 2 – 10 days.
• 2nd Degree
  There is more swelling specific to the ankle and increased ligament laxity. Players cannot heel raise, hop, or run, and recovery time is generally 10 – 30 days.
• 3rd Degree
  There is a lot of swelling and tenderness on the inside and outside of the ankle. With even more ligament laxity, the player cannot put any weight on the ankle, and recovery is generally 30 – 90 days.

Anterior Impingement Syndrome
Anterior impingement syndrome, better known as “Soccer Ankle”, has been shown to occur in roughly 60% of professional soccer players. Athletes generally feel pain in the front of the ankle, with feelings of giving way and catching, as well as pain with dorsiflexion movements (moving your foot up), squatting, sprinting and stair climbing. It has been proposed that recurrent ball impact results in microtrauma to the anterior joint, causing extra bony growth, which can become impinged with movement. Physical therapy treatment can be successful; however some athletes will require surgical intervention, which does have a high success rate.

Tendon and Muscle Strains
Tendon and muscle strains are another common overuse injury experienced in soccer players, with the achilles being the most common site of injury. To read a more comprehensive review on achilles tendon injuries and prevention strategies, click here.

Risk Factors

Several risk factors have been shown to predict who will sustain an ankle injury:

• Previous injuries increased the risk for an ankle injury by up to 7x – especially if previous injuries were poorly rehabilitated. Symptoms that become chronic can be an indicator that the previous injury has not been properly rehabilitated, and overuse will eventually lead to future injury.
• Muscle tightness or strength imbalance
• Slower reaction time
• Overuse
• Joint instability (Mechanical instability due to ligament laxity or functional instability due to poor proprioception, coordination and weakness).
• Poor balance and lower limb power (vertical jump)
• Insufficient training
• Inadequate warm up
• Increased age: Adolescent studies showed a high rate of injury in 12-15 year olds.
• Playing on artificial turf has been associated with a greater risk for ankle sprains
• Increased likelihood during competitions vs. training

Although there are several risk factors for ankle injuries, it is predicted that 30% of them are caused by a chance event that cannot be avoided.

Prevention Strategies

• Warm up:
  • An improper or lack of warm-up is one of the easiest ways to injure yourself. Take 5-10 minutes before games to warm up properly. Check out the FIFA11 warm-up program here.
• Stay in shape:
  • Preseason training should focus on muscle imbalances and weaknesses, with particular attention placed on proprioceptive exercises, especially in young adolescent soccer players.
• Follow the rules of the sport:
  • Unfair player contact accounts for 25% of soccer related ankle injuries
    Adequately rehab your injuries with sufficient rest time
• Protective equipment:
  • Shin guards have been shown to reduce the impact forces to the leg, reducing the occurrence of soft tissue and fracture injuries to the lower extremity. In addition, ankle braces have been shown to provide mechanical stability to the ankle joint, as well as increase proprioception in previously injured ankle joints.
• Focus on neuromuscular, balance and proprioceptive training:
  • Proprioceptive mechanoreceptors are found in the ligaments in the ankle. As such, injury to the ankle will likely damage these mechanoreceptors, resulting in a proprioceptive deficit and instability in the joint. If proper rehabilitation exercises are not completed prior to return to sport, then the athlete is at an increased risk for re-injury.
    Proprioceptive exercises should include balance training in a static position progressing to dynamic movements, including equipment such as the bosu, wobble disc and balance boards. Furthermore, plyometric exercises that enhance joint stabilization and reaction time exercises should be part of the return to sport training program.

With cooler weather coming, this marks the start of the indoor soccer season. Ensure your current injuries are well rehabilitated and spend some time working on your weaknesses (strength, proprioception, balance, etc.). Research has shown that indoor soccer is associated with twice as many injuries than outdoor soccer. Possible factors include high-speed movements, smaller size field, and surface changes. Focus on yourself now and don’t get stuck on the bench resting your injuries this indoor season.

Henry et al., (2015). Risk factors for noncontact ankle injuries in amateur male soccer players: A prospective cohort study. Clinical journal of sport medicine. 26:251-258.
Nery et al., (2016). Foot and ankle injuries in professional soccer players. Diagnosis, treatment and expectations. Foot and ankle clinic N. Am. 391-
McCann et al., (2018). Acute lateral ankle sprain prediction in collegiate women’s soccer players. The International Journal of Sports Physical Therapy. February 2018. Volume 13, Number 1.

For more info, contact Sheddon Physiotherapy and Sports Clinic at 905-849-4576.
We are located less than 10 min from Sheridan College Oakville and 4 min East from Oakville & Milton Humane Society.

The Burlington physio clinic is located only 5 min west of Spencer Smith Park and 6 min north-west of Burlington Beach, on Plains Rd East.