Soccer is the most popular sport in the world, and as such, it’s expected that a lot of athletes seek care for foot and ankle injuries sustained during practices or games both on recreational and competitive levels. In this article, we will discuss some of the most common ankle injuries in soccer, their associated mechanisms of injury, as well as general treatment strategies.
Lateral Ankle Sprains
A lateral ankle sprain, also known as an inversion sprain, is the most common ankle injury in general, and soccer is no exception. Rapid change-of-direction loading places a high demand on the ankle, and as such, the ankle can be more prone to forced inversion mechanisms of injury in soccer.
Lateral ankle sprains involve structural damage to the ligaments on the outside of the ankle, specifically, the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament. These ligaments provide passive support to the outside of the ankle, meaning they cannot be voluntarily contracted. You can think of these ligaments as stiff elastic bands that help constrain excessive motion of the ankle joint.
The mechanism of injury for a lateral ankle sprain is forced ankle inversion, or “rolling the ankle”, and can occur in various degrees of ankle plantarflexion or dorsiflexion. If this movement occurs too quickly with high enough force, the muscle surrounding the ankle will not be able to react quickly or strongly enough to prevent excessive ankle inversion, at which point the lateral ankle ligaments are susceptible to injury.
Treatment for a lateral ankle sprain begins with the R.I.C.E. protocol in the early stages, followed quickly by restoration of active range of motion and foot intrinsic muscle strength. As the ligaments continue to heal and begin entering the remodelling phase of healing, it is important to continue strengthening the ankle as tolerated, as this will promote overall ankle stability, which is especially important if laxity in the ligaments is now present.
Ankle strengthening typically begins using resistance bands. This allows the athlete to build foundational strength by isolating different muscle groups and strengthening them throughout the ankle’s available range of motion.
As strength and tolerance to weight bearing improves, strengthening then progresses to take on a more functional form and includes a high degree of proprioception (joint position awareness), such as single leg static and dynamic stability on an unstable surface. Proprioception is extremely important in soccer-specific rehab, as it plays a huge role in both injury prevention and overall performance, especially when ligament laxity is present (Ergen and Ulkar, 2008).
The most advanced phase of rehab for a lateral ankle sprain in soccer is return-to-sport training. This is basically strengthening the ankle in a manner that it is likely to be stressed in soccer, including plant and cut activities, dynamic exercises that include the use of a soccer ball, and scrimmaging with their team. More specific rehab exercises, for example those involving balance training, may still be involved.
Given that ankle sprains are more likely to occur in those with a history of sprains, improving ankle strength and stability is paramount not only for proper rehab, but also for reducing the risk of re-injury. Another strategy that can assist in stabilizing the ankle during high-risk activities like soccer is the application of an ankle brace, particularly a lace-up ankle brace, also known as an ankle stabilization orthosis (ASO brace).
Medial Ankle Sprains
Medial ankle sprains, also known as eversion ankle sprains, involve torn ligaments on the inside of the ankle, specifically the deltoid ligament, and while far less common than lateral ankle sprains, they do still occur at a relatively high frequency in competitive soccer.
The mechanism of injury for a medial ankle sprain is forced ankle eversion, which is basically forcing the inside of the ankle into excessive stretch. This is not the typical rolled ankle mechanism like a lateral ankle sprain, and instead is usually associated with more awkward maneuvers or some form of contact.
For example, sprinting in a forward direction and planting the right foot to push off towards the right can represent a potential mechanism of injury for a medial ankle sprain if the ankle cannot maintain its stability during this change of direction maneuver.
In the sense of sustaining contact, a slide tackle, whereby contact to the outside of a planted ankle forces the inside of the ankle to “open up” into a valgus position, can also be a way to sustain damage to the deltoid ligament. Similarly, jumping up for a header and landing on someone else’s cleat can also force the ankle into this position.
The deltoid ligament is actually considered a complex, meaning it is composed of a number of different ligaments. While stress testing the ligament different positions of ankle plantarflexion and dorsiflexion can help identify specific bands that may be damaged, rehab typically follows the same general course as lateral ankle sprains, and as long as other serious pathologies are ruled out, such as a fracture, conservative rehab via physiotherapy is typically successful in treating a medial ankle sprain.
High Ankle Sprains
High ankle sprains represent another common form of ankle injury in soccer with, primarily due to soccer players being prone to this particular mechanism of injury. The mechanism of injury for a high ankle sprain is forced dorsiflexion, usually with a component of external rotation, and typically sustained in a weight-bearing position. This can occur when landing from a header, awkwardly stepping on another player’s cleat, or being on the receiving end of a slide tackle.
The reason this mechanism of injury can lead to a high ankle sprain is because it places stress on the anterior inferior tibiofibular ligament which supports the ends of the tibia and fibula at the ankle joint. When forced into dorsiflexion and external rotation, the ends of these bones will splay to accommodate that motion, and if this exceeds their normal capacity to accommodate this, the ligament will sustain structural damage.
One of the main differences for treatment between high ankle sprains and lateral ankle sprains is that a high ankle sprain typically requires some level of immobilization, the extent to which is proportional to the extent of injury. As such, many soccer players will miss more time with a high ankle sprain relative to lateral ankle sprains (Gulbrandsen et al, 2019). For moderate cases, it’s typically recommended to place the ankle in a walking boot for ~ 6 weeks and weight-bearing status may also be adjusted during this time.
While certainly inconvenient, this form of immobilization will help offload the distal tibiofibular joint and will dampen the forces that typically place stress on the affected ligament, allowing it heal appropriately. From there, the rehabilitation process will look similar to a lateral ankle sprain; however, there may be subtle difference in the amount of focus on a particular area, for example, restoration of range of motion (especially into dorsiflexion), gradual return to weight bearing and impact activities, and improvement of overall joint proprioception. Items like an ASO ankle brace also help facilitate gradual return to activity, but does not replace activity-based rehab altogether.
Muscle strains are common in any sport, especially competitive sports, as the athlete is required to push their bodies to the limit. According to Ekstrand et al (2011), muscle injuries accounted for 31% of all injuries in soccer and caused 27% of the total injury absence in a sample consisting of 2299 soccer players across 51 teams from 2001-2009.
A strain refers to an injured muscle or tendon, whereby the force exerted on the body is more than the muscle itself can withstand. Strains are also commonly referred to as “torn muscles” or “pulled muscles”. Similar to ligaments, strains can be classified in various degrees of injury.
A Grade 1 strain involves mild disruption of the muscle tissue. Grade 1 strains can be quite painful, but overall function is largely maintained and recovery times are a bit quicker. Grade 2 injuries represent large scale damage or tearing to the muscle, but not a complete rupture. These injuries are very painful, and it will be painful to both contract and stretch the muscle. Recovery times for Grade 2 strains are much longer than Grade 1 strains. Grade 3 strains represent full ruptures to the muscle and occasionally require surgical intervention.
While muscle strains are common in soccer, they can still be fairly tricky to treat, especially if there is pressure on the athlete to continue playing. Contraction and stretching of the muscle will be painful and may cause further damage, so it is important that the athlete is closely monitored by a physiotherapist or doctor throughout their recovery.
Treatment for muscle strains typically focuses on providing an optimal environment for healing (R.I.C.E. in the early stages), followed by gradual restoration of strength and mobility of that muscle. Caution needs to be taken in order to not over-stress the muscle to the point of further damage or restarting an inflammatory cycle, which is why advice from a physiotherapist is highly recommended. Strengthening begins very gentle and often in stationary positions and gradually progresses to more functional strengthening and ultimately return-to-sport.
The most commonly injured ankle muscles in soccer are the calf muscles. According to Ekstrand et al (2011), calf muscles represented 13% of all muscle strains occurring in soccer players. The calf muscles and their associated Achilles tendon are the powerhouse for propulsion during running and are highly active in the toe-off phase of running. Additionally, they help to control ankle dorsiflexion, which means they are highly active during deceleration and plant + cut maneuvers.
If the calf muscles are stretched too rapidly, especially while being loaded, an injury from a minor strain to a full rupture of the muscles or Achilles tendon is possible. For more minor strains, a similar rehab process is followed as outlined above, and in severe cases of full rupture, surgical intervention may be warranted, although conservative rehab is becoming more common for calf and Achilles ruptures.
The peroneal muscles (also known as fibular muscles) are also commonly injured, just not to the same extent as the calf muscles. The peroneal muscles provide support to the outside of the foot and ankle. These muscles are often injured during forced ankle inversion, which is why they are often injured in combination with the lateral ankle ligaments. This is a very important muscle group to keep strong for rehab and injury prevention in the context of lateral ankle sprains and strains.
Ankle fractures, also known as a broken ankle, involve structural damage to one or more bones of the ankle joint. The ankle, especially the distal aspect of the fibula, is the most common lower limb fracture site in soccer. Demographic factors that may increase one’s risk of sustaining an ankle fracture while playing soccer include amateur status, older age, and male gender (Robertson et al, 2022).
The mechanism of injury for this type of ankle fracture is usually similar to a lateral ankle sprain; however, the forces involved are typically higher and/or more rapid and may be concentrated more towards the distal fibula. While non-contact mechanisms, such as a plant and cut maneuver or landing awkwardly from a header, can lead to an ankle fracture, they are more commonly seen with some form of trauma. This trauma can be something isolated like a slide tackle impact to the outside of the leg, or may be more convoluted like one or more players falling on the outside of another player’s ankle.
Treatment for an ankle fracture sustained during soccer can be surgical or conservative. Surgical interventions usually involve open reduction internal fixation, also known as an ankle ORIF, which is basically fixing the bone directly with screws and plates that may or may not be removed at a future date. Conservative treatment usually involves rest, immobilization, non-weight bearing, and other protective strategies in the early stages, followed by progressive activity-based rehab to restore function and reduce risk of re-injury.
Immobilization will be required to some degree in the early stages to allow the bones to properly heal. Once there is some evidence of bone healing, which is usually assessed on x-ray, gentle physiotherapy may begin with caution to ensure not disrupting the healing process. As the bones continues to heal, physiotherapy may become more comprehensive by way of combining range of motion and strengthening exercises, eventually leading to functional strengthening in weight-bearing positions, and ultimately, return to sport.
When it comes to return to sport, evidence shows a discrepancy between recreational and professional soccer players in terms of the amount of time it takes to get back into the game. According to Robertson et al, 2022, the average time for a recreational soccer player from the general population to return to soccer after an ankle fracture was about 31 weeks, compared with about 13 weeks for professional soccer players. This difference likely has to do with a higher level, specificity, and intensity of rehab involved for professional soccer players, as well as their motivation and professional obligation to return to the game as soon as possible.
Other Ankle Injuries in Soccer
The sprains, strains, and fractures listed above represent the most common foot and ankle injuries in soccer, but that doesn’t mean other injuries can occur. For example, Achille’s tendon ruptures, various tendinopathies, Lisfranc injuries, etc, can also occur, but their presentations can vary widely and are generally less common. For more information on these injuries, please feel free to browse through the linked articles, as the information there will still apply to soccer players.
Final Words on Treatment
Regardless of the type of injury, it is highly recommended to seek care from a physiotherapist or athletic therapist if you are a soccer player who has sustained an ankle injury. Don’t be surprised if the initial phases of rehab appear somewhat general and lack sport-specific elements. The early stages are all about continuing to provide an optimal environment for healing while progressively restoring function to the ankle.
Once the rehab reaches more advanced phases that involve functional strengthening, sport-specific elements now become involved, and rehab exercise begin to resemble fitness and sport-specific training, just with a focus on the injury being treated. A physiotherapist or athletic therapist will be able to optimize the rehab plan to incorporate as much soccer-specific training as possible, allowing the athlete to regain their baseline level of performance while also reducing the risk of re-injury.
Ekstrand, J., Hägglund, M., & Waldén, M. (2011). Epidemiology of muscle injuries in professional football (soccer). The American journal of sports medicine, 39(6), 1226-1232.
Ergen, E., & Ulkar, B. (2008). Proprioception and ankle injuries in soccer. Clinics in sports medicine, 27(1), 195-217.
Gulbrandsen, M., Hartigan, D. E., Patel, K. A., Makovicka, J. L., Tummala, S. V., & Chhabra, A. (2019). Ten-year epidemiology of ankle injuries in men’s and women’s collegiate soccer players. Journal of athletic training, 54(8), 881-888.
Robertson, G. A., Ang, K. K., & Jamal, B. (2022). Fractures in soccer: The current evidence, and how this can guide practice. Journal of orthopaedics.
The content here is designed for information & education purposes only and is not intended for medical advice.