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Time-trends and circumstances surrounding ankle injuries in men's professional football: An 11-year follow-up of the UEFA Champions League injury study

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Ankle injury is common in football, but the circumstances surrounding them are not well characterised. To investigate the rates, especially time-trends, and circumstances of ankle injuries in male professional football. 27 European clubs with 1743 players were followed prospectively between 2001/2002 and 2011/2012. Time loss injuries and individual-player exposure during training sessions and matches were recorded. Injury rate was defined as the number of injuries/1000 h. A total of 1080 ankle injuries were recorded (13% of all injuries) with lateral ligament ankle sprain being the most common injury subtype (51% of all ankle injuries). The rates of ankle injury and ankle sprain were 1/1000 h and 0.7/1000 h, respectively. The ankle sprain rate declined slightly over time during the 11-year study period (on average 3.1%/season) with a statistically significant seasonal trend (p=0.041). Foul play according to the referee was involved in 40% of the match-related ankle sprains. Syndesmotic sprains and ankle impingement were uncommon causes of time loss (3% each of all ankle injuries). Lateral ligament ankle sprain constituted half of all ankle injuries in male professional football, whereas ankle impingement syndromes were uncommon. The ankle sprain rate decreased slightly over time, but many ankle sprains were associated with foul play. Our data extend the body of literature that provides football policy makers with a foundation to review existing rules and their enforcement.
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Time-trends and circumstances surrounding ankle
injuries in mens professional football: an 11-year
follow-up of the UEFA Champions League
injury study
Markus Waldén,
1,2
Martin Hägglund,
2,3
Jan Ekstrand
1,2
Additional material is
published online only. To view
please visit the journal online
(http://dx.doi.org/10.1136/
bjsports-2013-092223).
1
Division of Community
Medicine, Department of
Medical and Health Sciences,
Linköping University,
Linköping, Sweden
2
Football Research Group,
Linköping University,
Linköping, Sweden
3
Division of Physiotherapy,
Department of Medical and
Health Sciences, Linköping
University, Linköping, Sweden
Correspondence to
Dr Markus Waldén, Division of
Community Medicine,
Department of Medical and
Health Sciences, Linköping
University, Linköping 581 83,
Sweden,
markus.walden@telia.com
Accepted 1 April 2013
To cite: Waldén M,
Hägglund M, Ekstrand J. Br
J Sports Med 2013;47:
748753.
ABSTRACT
Background Ankle injury is common in football, but
the circumstances surrounding them are not well
characterised.
Aim To investigate the rates, especiall y time-trends, and
circumstances of ankle injuries in male professional
football.
Methods 27 European clubs with 1743 players were
followed prospectively between 200 1/2002 and 2011/
2012. Time loss injuries and individual-player exposure
during training sessions and matches were recorded.
Injury rate was de ned as the number of injuries/1000 h.
Results A total of 1080 ankle injuries were recorded
(13% of all injuries) with lateral ligament ankle sprain
being the most common injury subtype (51% of all
ankle injuries). The rates of ankle injury and ankle sprain
were 1/1000 h and 0.7/1000 h, respectively. The ankle
sprain rate declined slightly over time during the 11-year
study period (on average 3.1%/season) with a
statistically signicant seasonal trend (p=0.041). Foul
play according to the referee was involved in 40% of the
match-related ankle sprains. Syndesmotic sprains and
ankle impingement were uncommon causes of time loss
(3% each of all ankle injuries).
Conclusions Lateral ligament ankle sprain constituted
half of all ankle injuries in male professional football,
whereas ankle impingement syndromes were uncommon.
The ankle sprain rate decreased slightly over time, but
many ankle sprains were associated with foul play. Our
data extend the body of literature that provides football
policy makers with a foundation to review existing rules
and their enforcement.
INTRODUCTION
Ankle injuries account for 1018% of all injuries in
high-level football.
18
Sprains constitute between
51% and 81% of all ankle injuries in these studies,
and more than three-quarter of the ankle sprains
affect the lateral ligaments.
24
Many ankle sprains
occur as a result of player contact,
911
often with
tackling and foul play involved,
910
and a common
football-specic injury mechanism with direct
impact on the medial aspect of the lower leg by an
opponent tackling before or at foot strike resulting
in a forced inversion of the ankle joint has been
described.
10
The epidemiology of ankle sprains in football is
fairly well described, but knowledge about other
ankle injuries, such as fractures and impingement,
on the overall injury burden and player availability
is scarce. Previous studies suggest that the ankle
sprain rate is lower nowadays than during the
1980s and 1990s,
561216
but long-term prospect-
ive studies that have investigated the development
of ankle injuries over time are lacking. We investi-
gated the rates, especially time-trends, and circum-
stances of ankle injuries in male professional
football in Europe over 11 consecutive seasons.
MATERIALS AND METHODS
The current survey is a substudy of a prospective
cohort study evaluating male professional football
in Europe in collaboration with the Union of
European Football Associations.
8
A total of 27
clubs from 10 countries with 1743 players (a mean
squad size of 28 players were followed over a
varying number of seasons from 2001 to 2012
(160 club-seasons and 4375 player-seasons were
included for analysis).
17
The studied seasons were
divided into preseason ( July and August) and com-
petitive season (SeptemberMay). The study design
adheres to the consensus statement on injury deni-
tions and data collection procedures in football,
18
and the general methodology has been reported
elsewhere.
19
Supplementary online-only les 1
and 2 show the study design and the forms used
and also the manual with practical instructions.
Inclusion criteria and denitions
All players belonging to the rst team squads in
each season were eligible for inclusion. Players who
were transferred to other clubs or nished their
contracts due to other reasons before the end of a
season were included for as long as they partici-
pated. Injury was dened according to time loss
(table 1), and players were considered injured until
the club medical staff allowed full participation in
training and availability for match selection.
18 19
For the purpose of this study, the ankle (talocrural)
region included the tibiotalar and the inferior tibio-
bular joints as well as the surrounding stabilising
connective soft tissue (ie, joint capsules and liga-
ments) of these joints and the overlying skin.
Achilles tendon pathology was classied as lower
leg injuries
18
and, similarly, the pathology of other
tendons passing from the lower leg to the foot was
classied by the study group as lower leg or foot
injuries depending on the injury location. Ankle
sprains were classied as capsular, lateral (anterior
talobular, calcaneobular and posterior talobular
ligaments), medial (deltoid ligament) and high
(tibiobular syndesmosis). Reinjuries were dened
according to the concept of early recurrences.
18
Waldén M, et al. Br J Sports Med 2013;47:748753. doi:10.1136/bjsports-2013-092223 1 of 6
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Data collection
A member of the medical or coaching staff registered individual
player exposure in minutes during all club (rst team, second
team or youth team) and national team training sessions and
matches. All injuries were recorded immediately after the event
by a club medical ofcer. Injury cards and attendance records
were sent to the study group once a month. The injury card was
slightly modied during the study period in that all injuries had
to be classied as contact or non-contact injuries starting from
the 2004/2005 season and the minute of injury was recorded
for all match injuries from the 2005/2006 season. Each injury
was coded according to a modied version of the Orchard
Sports Injury Classication System V.2.0.
20
Statistical analyses
Continuous data for anthropometrics were presented as the
mean with corresponding SD, and lay-off times were presented
as both mean±SD and median with corresponding IQR. Injury
rate (IR) was calculated as the number of injuries per 1000 h
with corresponding 95% CI. Injury burden was calculated as
the number of lay-off days per 1000 h. IRs were compared
using a rate ratio (RR) and signicance tested with z-statistics.
21
The seasonal trend for ankle injuries in general and ankle
sprains, expressed as the average annual percentage of change,
was analysed using linear regression with log-transformed IRs as
a dependent variable. A 2-year moving average (MA) approach,
by summarising two consecutive seasons, was also used to
smooth out large seasonal variation. Owing to a skewed distri-
bution, differences in lay-off times were analysed using the
Mann-Whitney U test for reinjuries and the Kruskal-Wallis test
for ankle sprain categories. Injury occurrence between the six
15 min periods of a match was analysed using the one-sample
proportional z test. All analyses were two-sided and the signi-
cance level was set at p<0.05.
RESULTS
A total of 8029 injuries were recorded during 1 057 201 expos-
ure hours (888 249 training and 168 952 match). There were
1080 ankle injuries (427 training and 653 match), thus constitut-
ing 13% of all injuries. The overall ankle IR was 1/1000 h (table 2),
which means that a professional football club with a 25-player
squad will suffer around seven ankle injuries in each season.
Ankle sprain was the single most common injury type (table 2),
constituting 68% of all ankle injuries and 9% of all injuries. The
overall ankle sprain rate was 0.7/1000 h (table 2), and a profes-
sional 25-player squad will thus suffer an average of four to ve
ankle sprains in each season. The MA approach indicated an
average annual IR decrease of 1.7% for ankle injuries in general,
but the seasonal trend in the regression model was not signicant
(R
2
=0.12, b=0.011, 95% CI 0.034 to 0.012, p=0.30).
Similarly, an average annual IR decrease of 3.1% for ankle
sprains was indicated in the MA approach (gure 1), with a statis-
tically signicant seasonal trend in the regression model
(R
2
=0.39, b=0.030, 95% CI 0.059 to 0.002, p=0.041).
When comparing preseason and competitive season (gure 2),
there were no statistically signicant differences in ankle IRs
during training (0.51/1000 h vs 0.48/1000 h, RR 1.06, 95% CI
0.84 to 1.34, p=0.60) or match play (4.13/1000 h vs 3.81/
1000 h, RR 1.08, 95% CI 0.88 to 1.33, p=0.45), as well as in
ankle sprain rates during training (0.34/1000 h vs 0.33/1000 h,
RR 1.05, 95% CI 0.79 to 1.38, p=0.76) or match play (2.86/
1000 h vs 2.53/1000 h, RR 1.13, 95% CI 0.87 to 1.45, p=0.32).
Three-quarter of the sprains affected the lateral ligaments,
whereas only 5% were high syndesmotic injuries (table 2). More
sprains occurred to the dominant leg (542/729), and the differ-
ences in IRs between the dominant and non-dominant ankles
were statistically signicant (0.51/1000 h vs 0.18/1000 h, RR
2.90, 95% CI 2.45 to 3.42, p<0.0001). The IRs for the differ-
ent sprain categories were between 3 and 10 times higher
during match play compared with training (table 3).
Second to joint and ligament injuries, contusions were most
common and constituted approximately every sixth ankle injury,
whereas only 18 fractures were reported (table 2). Ankle
impingement syndromes were uncommon causes of time loss
(table 2). The rate of posterior impingement was more than
threefold higher than that of anterior impingement (0.024/
1000 h vs 0.007/1000 h, RR 3.57, 95% CI 1.54 to 8.26,
p=0.003). Most of the impingement syndromes affected the
dominant ankle (5/7 in anterior and 16/25 in posterior).
Injury circumstances
From season 2004/2005 and forward, 566 ankle sprains were
classied according to contact or non-contact (six cases
missing), with more than half of them being the result of player
Table 1 Operational definitions used in study
Training session Team training that involved physical activity under the supervision of the coaching staff
Match Competitive or friendly match against another team
Injury Any physical complaint sustained by a player that resulted from a football match or football training and led to the player being unable to take
full part in future football training or match play
Ankle injury Injury to the tibiotalar and the inferior tibiofibular joints as well as the surrounding stabilising connective soft tissue (ie, joint capsules and
ligaments) of these joints and the overlying skin
Slight/minimal injury Injury causing 03 days lay-off
Mild injury Injury causing 47 days lay-off
Moderate injury Injury causing 828 days lay-off
Severe injury Injury causing >28 days lay-off
Traumatic injury Injury with sudden onset and known cause
Overuse injury Injury with insidious onset and no known trauma
Reinjury Injury of the same type and at the same site as an index injury occurring within 2 months after return to full participation from the index injury
Non-contact injury Injury occurring without contact with another player or object
Dominant leg Preferred kicking leg
Foul play Violation of the laws of the game according to the match referee
Injury rate Number of injuries per 1000 player hours ((Σ injuries/Σ exposure hours)×1000)
Injury burden Number of lay-off days per 1000 player hours ((Σ lay-off days/Σ exposure hours)×1000)
2 of 6 Waldén M, et al. Br J Sports Med 2013;47:748753. doi:10.1136/bjsports-2013-092223
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contact (58%). Foul play (own or opponent) was involved in
40% of the match-related ankle sprains, but few of these fouls
were sanctioned with a yellow or red card (5.8%). Additionally,
the minute of injury was reported for 285 ankle sprains occur-
ring during match play from season 2005/2006 and forward (35
cases missing). Signicantly fewer ankle sprains than expected
occurred during the rst 15 min of the rst half (11.2% vs
16.7%, p=0.014), whereas no signicant differences were
detected for the rest of the 15 min periods (gure 3).
Injury severity
In total, 13% of the ankle injuries were severe (table 4). The
average lay-off per ankle injury was 16±27 (median 8, IQR 15)
days with the injury burden completely dominated by lateral
ligament sprain (table 4). High ankle sprains had an average
lay-off of 43±33 (median 34, IQR 37) days and this was signi-
cantly longer than the other three ankle sprain categories
(p<0.0001). Finally, there were three avulsion fractures of the
lateral malleolus causing a lay-off between 6 and 15 days,
whereas all other ankle fractures were severe with an average
lay-off of 103±45 (median 93, IQR 50) days.
Table 2 Frequency, injury rate and injury recurrence of all ankle injury types in male professional football
Number of injuries (%) IR* 95% CI Number of re-injuries (%)
Fracture and bone stress 22 (2.0) 0.021 0.014 to 0.032 1 (4.5)
Fractures 18 (1.7) 0.017 0.011 to 0.0027 1 (5.6)
Other bone stress 4 (0.4) 0.004 0.001 to 0.010 0
Joint and ligament 744 (68.9) 0.704 0.655 to 0.756 78 (10.5)
Dislocation/subluxation 3 (0.3) 0.003 0.001 to 0.009 0
Sprain/ligament injury 729 (67.5) 0.690 0.641 to 0.742 75 (10.3)
Capsular 67 (9.2) 0.063 0.050 to 0.081 5 (7.5)
Lateral 552 (75.7) 0.522 0.480 to 0.568 58 (10.5)
Medial 72 (9.9) 0.068 0.054 to 0.086 8 (11.1)
High 38 (5.2) 0.036 0.026 to 0.049 4 (10.5)
Cartilage lesion 12 (1.1) 0.011 0.006 to 0.020 3 (25.0)
Contusion 182 (16.9) 0.172 0.149 to 0.199 0
Laceration and skin lesion 10 (0.9) 0.010 0.005 to 0.018 1 (10.0)
Peripheral nervous system 2 (0.2) 0.002 0.001 to 0.008 0
Other 120 (11.1) 0.114 0.095 to 0.136 41 (34.2)
Synovitis 65 (6.0) 0.062 0.048 to 0.078 26 (40.0)
Impingement 32 (3.0) 0.030 0.021 to 0.043 4 (12.5)
Anterior 7 (0.6) 0.007 0.003 to 0.014 2 (28.6)
Posterior 25 (2.3) 0.024 0.016 to 0.035 2 (8.0)
Instability 7 (0.6) 0.007 0.003 to 0.014 3 (42.9)
Unspecified pain 12 (1.1) 0.011 0.006 to 0.020 3 (25.0)
Osteoarthritis 2 (0.2) 0.002 0.001 to 0.008 0
Sinus tarsi syndrome 2 (0.2) 0.002 0.001 to 0.008 1 (50.0)
Total 1080 (100) 1.022 0.962 to 1.084 121 (11.2)
*Injury rate (IR) is expressed as the number of injuries per 1000 h.
Figure 2 Seasonal distribution of injury rates in male professional
football. Injury rate is expressed as the number of injuries per 1000 h.
Figure 1 Injury rates for ankle sprain per season. Injury rate is
expressed as the number of injuries per 1000 h. The dark grey line
shows the 2-year moving average injury rate calculated as the sum of
two consecutive seasons.
Waldén M, et al. Br J Sports Med 2013;47:748753. doi:10.1136/bjsports-2013-092223 3 of 6
Original article
Reinjuries
In total, 11% of all ankle injuries and 10% of ankle sprains
were classied as reinjuries (table 2). No signicant difference in
average lay-off was seen between recurrent sprains and other
sprains (15±19 (median 9, IQR 13) vs 15±21 (median 8, IQR
15 days), p=0.87).
DISCUSSION
The principal nding of this study was that 40% of the
match-related ankle sprains occurred as a result of foul play.
Other important ndings were that almost every 10th football
injury was an ankle sprain and that the ankle sprain rate showed
a statistically signicant decreasing trend over the 11-season
study period. Finally, ankle impingement was an uncommon
cause of time loss during the seasons studied, especially the
anterior impingement.
Ankle injury epidemiology
In a large-scale review of 227 studies on 70 different sports
22
foot-
ball was a high-risk sport for ankle injury, particularly ankle sprain.
We found that 68% of all ankle injuries were sprains and this
nding extends the previous literature.
18
Historically, ankle sprain
used to be the most common football injury and studies from male
high-level football conducted during the 1980s and 1990s
reported overall ankle sprain rates as 1.8/1000 h and 1.3/1000 h,
respectively.
12 13
In more recent studies conducted from 1999 and
later, however, the ankle sprain rate has been considerably lower
(0.50.8/1000 h).
561416
The overall ankle sprain rate in the
current study was 0.7/1000 h, and it thus seems that the current
ankle sprain rate is lower than that historically attributed.
Interestingly, there was a trend of a further decline over time with
an average annual decrease in the ankle sprain rate of 3%.
The most plausible explanation to the lower ankle sprain rate
nowadays and the declining trend is successful implementation
of strategies in the clubs such as balance board training and
taping/bracing for preventing recurrent ankle sprains,
2326
although no such player data were collected in this study.
Another contributing factor could be that more training now
than before is devoted to low-risk activities such as recovery
sessions, resistance training and physical conditioning, making
the overall ankle sprain rates lower.
Foul play was involved in 40% of the match play ankle
sprains. This nding is in line with the results in a previous sys-
tematic video analysis study of Norwegian and Icelandic elite
football where many ankle sprains were shown to result from
late tackles, sometimes even intentional fouls, without penalty
to the offending player.
10
We therefore call for stricter enforce-
ment of the existing rules or introduction of new rules such as
timed suspensions to be able to prevent these frequent
contact-related injuries that theoretically would be very difcult
to prevent with balance training or ankle support.
Ankle sprain frequency at different stages of matches
In two studies on male professional and amateur football, ankle
sprains were more frequent in the last thirds of both halves,
411
without formal statistics, whereas no such trend was detected in
the current study.
No worries for footballers ankle?
Although given increasing attention in recent years,
27 28
anterior
and posterior ankle impingement syndromes were quite infre-
quent in this study and constituted only 3% of all ankle injuries.
Considering that anterior ankle impingement historically was
called footballers ankle,
29 30
the posterior impingement rate
was, somewhat surprisingly, more than threefold higher in the
current study. The problem with ankle impingement is, however,
most probably underestimated due to the use of a time loss injury
denition,
31
and players might be able to play despite their symp-
toms and are perhaps not referred to denitive treatment until
the season is over. As only 4 of the 32 impingement injuries in
Table 3 Match and training injury rates for the most common ankle injury types in male professional football with corresponding rate ratios
Match IR* 95% CI Training IR* 95% CI RR 95% CI
All ankle injuries 3.865 3.580 to 4.173 0.481 0.437 to 0.529 8.04 7.12 to 9.08
Fractures 0.065 0.036 to 0.112 0.008 0.004 to 0.118 8.26 3.20 to 21.31
Sprain/ligament injury 2.581 2.350 to 2.835 0.330 0.294 to 0.370 7.82 6.75 to 9.07
Capsular 0.160 0.110 to 0.233 0.045 0.033 to 0.061 3.46 2.13 to 5.63
Lateral 2.024 1.821 to 2.251 0.236 0.207 to 0.271 8.56 7.21 to 10.17
Medial 0.249 0.184 to 0.336 0.034 0.024 to 0.048 7.36 4.61 to 11.58
High 0.148 0.100 to 0.219 0.015 0.009 to 0.025 10.11 5.17 to 19.73
Contusion 0.817 0.691 to 0.965 0.050 0.037 to 0.067 16.49 11.74 to 23.15
Synovitis 0.142 0.095 to 0.212 0.046 0.034 to 0.063 3.08 1.86 to 5.09
Impingement 0.095 0.058 to 0.155 0.018 0.011 to 0.029 5.26 2.63 to 10.51
Anterior 0.024 0.009 to 0.063 0.003 0.001 to 0.011 7.01 1.57 to 31.32
Posterior 0.071 0.040 to 0.125 0.015 0.009 to 0.025 4.85 2.21 to 10.64
*Injury rate (IR) is expressed as the number of injuries per 1000 h.
Rate ratio is expressed as the match injury rate divided by the training injury rate.
Figure 3 Proportion of ankle sprains during the 15 min periods of
match play in male professional football.
4 of 6 Waldén M, et al. Br J Sports Med 2013;47:748753. doi:10.1136/bjsports-2013-092223
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the current study were categorised as severe, most of them were
obviously managed non-surgically in this setting.
Interestingly, almost two-thirds of the impingements occurred
to the preferred kicking leg (dominant ankle) in the current
study. It has previously been shown that a typical ankle injury
mechanism in football is a forced plantar exion where the
injured player hit an opponents foot when attempting to shoot
or clear the ball, and this anterior capsular traction mechanism
was suggested to contribute to the development of footballers
ankle.
10
However, since the anterior joint capsule attachments
are more proximal and distal to the sites where the talotibial
spurs originate, this theory has been questioned.
30
It is note-
worthy that a forced plantar exion not only leads to an anter-
ior traction force, but also to a forceful compression of the
bony and soft tissues on the posterior part of the ankle.
27
Thus,
the previously described injury mechanism for footballers
ankle could therefore be a more common cause of posterior
ankle impingement. This notion is supported by the fact that
posterior impingement was signicantly more common in the
current study than anterior impingement.
Injury severity
In total, 87% of the ankle sprains had a lay-off of less than
4 weeks, which is in line with a recent study from Swedish elite
football where this gure was 83%.
7
The mean lay-off per ankle
sprain was, however, 15 days in the current study compared with
only 8 days in that study. This apparent discrepancy could pos-
sibly reect a better safe than quick treatment algorithm that is
supported by the fact that the ankle sprain reinjury frequency
was low (10%).
Interestingly, almost two-thirds of the high ankle sprains were
severe and these injuries were associated with a substantially
longer lay-off than both the lateral and medial ligament sprains.
The athletic literature in this eld is scarce, but in a review of
1344 ankle sprains occurring in West Point cadets, only 10 high
ankle sprains were identied, but, in line with the current study,
these injuries required a considerably longer time to return to
full activity compared with grade III lateral ligament sprains
(mean 55 vs 28 days).
32
Methodological considerations
The prospe ctive design with rigorous data check-up and the
11-season study period to avoid the inuence of occa sional
extreme seasons are some important strengths of the present
study together with the large a nd homogeneous sample of pro-
fessional foo tballers. However, this study also has some
important limitations. First, no treatment details were
requested on the general injury card, and additionally, no sub -
study specic injury card was sent to the clubs as for some of
our previous substudies.
33 34
It would h ave been interestin g to
collect surgical data for the ankle fractures and impingement
syndromes, but it would prob ably be of minor value for ankle
sprains since the need for ligament surgery in professional
football has been shown to be minimal.
4
Second, no informa-
tion about the use of any preventive training such as balance
board training and coach-directed limitation o f p layer-contact
during training session s or the use of any protective equipment
such as bracing and taping was recorded, and these aspects
the re fore need to be addressed in future studies. Third, only
one diagnosis was recorded for each injury case in the database
(the main di agnosi s). In cases with multiple injuries s ustained
in the same even t (eg, a severe ankle ligament sprain with con-
comitant mild cartilage abnormalities on imaging), only the
most signicant injury i s captured in the injury surveillance.
Fourth, all tendon injuries were excluded from the denition
of ankle injury, and it could be argued that, for example, pos-
terior tibial and peroneal tendon injuries located posterior to
the malleoli should be included amo ng the ankle injuries. The
exact location of the tendon pathology was, however, not
requested on the injury card and the tendo n injuries were
therefore excluded from the ankle injury denition. Fifth, the
par tici pating clubs were not provided with any specicdiag-
nostic or return-to-play criteria in our study manual, and it is
therefore possible that the reported subclassications, lay-off
times and reinjury frequency varied between clubs due to the
different diagnostics and treatment algorithms. Sixth, no reli-
able history of previous injury was collected at player inclu-
sion, and i t was the refore not possible to com pare the ankle
sprain rates between uninjured players and players with prior
ankle sprain. It is, however, well kn own that players with pre-
vious ankle sprain during the career or the preceding season
have approximately 23 times higher rate of future ankle
sprain.
1215
Finally, the design of the injury card during the
rst seasons of the study did not include information about the
match minute of the injury and whether it resulted from
contact or not.
Table 4 Severity, lay-off and injury burden for the most common ankle injury types in male professional football
03 days* 47 days* 828 days* >28 days* Mean lay-off SD Median lay-off IQR Injury burden
All ankle injuries 270 311 360 139 15.9 27.1 7 13 16.3
Fractures 0 0 3 15 89.6 52.0 87 70 1.5
Sprain/ligament injury 141 212 279 97 15.4 20.5 8 15 10.6
Capsular 29 27 9 2 7.3 13.3 4 3 0.5
Lateral 100 157 233 62 14.7 19.2 8 14 7.7
Medial 11 26 26 9 13.6 15.4 7 12 0.9
High 1 2 11 24 43.2 33.0 34 37 1.6
Contusion 84 61 33 4 6.2 10.3 4 5 1.1
Synovitis 22 17 20 6 16.0 39.6 7 11 1.0
Impingement 11 8 9 4 12.1 16.4 6.5 8 0.4
Anterior 1 1 3 2 24.0 24.7 11 41 0.2
Posterior 10 7 6 2 8.8 11.9 5 7 0.2
*Injury severity is categorised according to lay-off days as slight/minimal (03), mild (47), moderate (828) and severe (>28).
Lay-off is expressed in days.
Injury burden expressed as the number of lay-off days per 1000 h.
Waldén M, et al. Br J Sports Med 2013;47:748753. doi:10.1136/bjsports-2013-092223 5 of 6
Original article
Clinical and policy implicationscall for action
In conclusion, lateral ligament ankle sprains constituted half of
all ankle injuries in male professional football, whereas the
anterior and posterior ankle impingement syndromes were infre-
quent. The ankle sprain rate showed a statistically signicant
decreasing trend over the 11-season study period, and although
the reasons for this cannot be ascertained from our study
design, it is consistent with a decreasing trend for ligament
injuries in general.
17
Many match-related ankle sprains were,
however, associated with foul play and this nding might
warrant a discussion in the international governing bodies about
stricter rule enforcement.
What this study adds
The ankle sprain rate in male professional football has
decreased signicantly over the past decade.
Foul play was involved in more than half of the ankle
sprains associated with player contact.
Ankle impingement syndromes, especially the anterior
footballers ankle, were uncommon causes of time loss.
How might it impact on clinical practice?
Ankle sprains are common and constitute more than half of all
ankle injuries in professional football. The decreasing trend in
the ankle sprain rate since 2001/2002, as shown in this study,
gives indirect evidence that injury prevention strategies have
been successful. These ndings might therefore serve as a
motivator among players, coaches, medical practitioners and
stakeholders for continuous preventive efforts in the sport.
Acknowledgements The authors would like to thank the participating clubs
(coaching and technical staff, medical teams and players) for their participation in
the study. Henrik Magnusson, MSc, is also acknowledged for statistical advice.
Contributors MW, MH and JE were responsible for the conception and design of
the study. All authors have been involved in the data collection over the study
period. MW and the statistical advisor conducted the analyses which were planned
and checked with the coauthors. All authors contributed to the interpretation of
ndings and had full access to all data. MW wrote the rst draft of the paper which
was critically revised by MH and JE. The nal manuscript has been approved by all
authors. MW is the study guarantor.
Funding This study was funded by grants from the Union of European Football
Associations (UEFA), Swedish National Centre for Research in Sports, and
Praktikertjänst AB.
Competing interests JE is the rst vice chairman of the UEFA Medical
Committee.
Ethics approval The study design was approved by the UEFA Medical Committee
and the UEFA Football Development Division.
Provenance and peer review Not commissioned; externally reviewed.
REFERENCES
1 Hawkins RD, Fuller CW. A prospective epidemiological study of injuries in four
English professional football clubs. Br J Sports Med 1999;33:196203.
2 Hawkins RD, Hulse MA, Wilkinson C, et al. The association football medical
research programme: an audit of injuries in professional football. Br J Sports Med
2001;35:437.
3 Morgan BE, Oberlander MA. An examination of injuries in major league soccer. The
inaugural season. Am J Sports Med 2001;29:42630.
4 Woods C, Hawkins RD, Hulse AM, et al. The Football Association Medical Research
Programme: an audit of injuries in professional football: an analysis of ankle
sprains. Br J Sports Med 2003;37:2338.
5 Waldén M, Hägglund M, Ekstrand J. Injuries in Swedish elite footballa
prospective study on injury denitions, risk for injury and injury pattern during
2001. Scand J Med Sci Sports 2005;15:11825.
6 Waldén M, Hägglund M, Ekstrand J. UEFA Champions League study: a prospective
study of injuries in professional football during the 20012002 season. Br J Sports
Med 2005;39:5426.
7 Hägglund M, Waldén M, Ekstrand J. Injuries among male and female elite football
players. Scand J Med Sci Sports 2009;19:81927.
8 Ekstrand J, Hägglund M, Waldén M. Injury incidence and inj ury patterns in
professional football: the UEFA Injury Study. Br J Sports Med 2011;45:5538.
9 Giza E, Fuller C, Junge A, et al. Mechanisms of foot and ankle injuries in soccer.
Am J Sports Med 2003;31:5504.
10 Andersen TE, Floerenes TW, Árnason Á, et al. Video analysis of the mechanisms for
ankle injuries in football. Am J Sports Med 2004;32(Suppl 1):69S79S.
11 Kofotolis ND, Kellis E, Vlachopoulos SP. Ankle sprain incidence and risk factors in
amateur soccer players during a 2-year period. Am J Sports Med 2007;35:45866.
12 Ekstrand J, Tropp H. The incidence of ankle sprains in soccer. Foot Ankle
1990;11:413.
13 Árnason Á, Gudmundsson Á, Dahl HA, et al. Soccer injuries in Iceland. Scand J
Med Sci Sports 1996;6:405.
14 Árnason À, Sigurdsson SB, Gudmundsson A, et al. Risk factors for injuries in
football. Am J Sports Med 2004;32:S5
16.
15 Hägglund M, Waldén M, Ekstrand J. Previous injury as a risk factor for injury in elite
football: a prospective study over two consecutive seasons. Br J Sports Med
2006;40:76772.
16 Fousekis K, Tsepis E, Vagenas G. Intrinsic risk factors of noncontact ankle sprains in
soccer: a prospective study on 100 professional players. Am J Sports Med
2012;40:184250.
17 Ekstrand J, Hägglund M, Kristenson K, et al. Less ligament injuries but no
preventive effect on muscle injuries and severe injuriesan 11-year follow up of
the UEFA Champions League injury study. Br J Sports Med 2013;47:73842.
18 Fuller CW, Ekstrand J, Junge A, et al. Consensus statement on injury denitions and
data collection procedures in studies of football (soccer) injuries. Br J Sports Med
2006;40:193201.
19 Hägglund M, Waldén M, Bahr R, et al. Methods for epidemiological study of
injuries to professional football (soccer) players: developing the UEFA model. Br J
Sports Med 2005;39:3406.
20 Orchard J. Orchard Sports Injury Classi cation System (OSICS). Sport Health
1993;11:3941.
21 Lindenfeld T, Schmitt DJ, Hendy M, et al. Incidence of injury in indoor soccer. Am J
Sports Med 1994;22:36471.
22 Fong DT, Hong Y, Chan L, et al. A systematic review on ankle injury and ankle
sprain in sports. Sports Med 2007;37:7394.
23 Tropp H, Askling C, Gillquist J. Prevention of ankle sprains. Am J Sports Med
1985;13:25962.
24 Surve I, Schwellnus MP, Noakes T, et al.Avefold reduction in the incidence of
recurrent ankle sprains in soccer players using the Sport-Stirrup orthosis. Am J
Sports Med 1994;22:6015.
25 Sharpe SR, Knapik J, Jones B. Ankle braces effectively reduce recurrence of ankle
sprains in female soccer players. J Athl Train 1997;32:214.
26 Mohammadi F. Comparison of 3 preventive methods to reduce the recurrence of
ankle inversion sprains in male soccer players. Am J Sports Med 2007;35:9226.
27 Calder JD, Sexton SA, Pearce CJ. Return to training and playing after posterior ankle
arthroscopy for posterior impingement in elite professional soccer. Am J Sports Med
2010;38:1204.
28 Hess GW. Ankle impingement syndromes: a review of etiology and related
implications. Foot Ankle Spec 2011;4:2907.
29 McMurray TP. Footballers ankle. J Bone Joint Surg [Br] 1950;32B:689.
30 Tol JL, van Dijk CN. Anterior ankle impingement. Foot Ankle Clin
2006;11:297310.
31 Bahr R. No injuries, but plenty of pain? On the methodology for recording overuse
symptoms in sports. Br J Sports Med 2009;43:96672.
32 Hopkinson WJ, St Pierre P, Ryan JB, et al. Syndesmosis sprains of the ankle. Foot
Ankle 1989;10:15660.
33 Waldén M, Hägglund M, Magnusson H, et al. Anterior cruciate ligament injury in
elite football: a prospective three-cohort study. Knee Surg Sports Traumatol Arthrosc
2011;19:1119.
34 Ekstrand J, Healy JC, Waldén M, et al. Hamstring muscle injuries in professional
football: the correlation of MRI ndings with return to play. Br J Sports Med
2012;46:11217.
6 of 6 Waldén M, et al. Br J Sports Med 2013;47:748753. doi:10.1136/bjsports-2013-092223
Original article
... [10][11][12][13] Along with muscle (33-35%) [14][15][16][17] and knee joint injuries (15%-21%), 14,[16][17][18][19][20] trauma to the ankle is the third most common type of injury in professional football. 17,[21][22][23] The injury rate is still high despite a decreasing trend in the injury frequency of ligamentous ankle injuries in professional soccer 24 : 10-18% of the occurring injuries in professional football involve the ankle. 15,17,19,21,[25][26][27][28][29] Of this, ligamentous injuries (ankle sprains) account for a large proportion of occurring ankle injuries, with 62-69%. ...
... 15,17,19,21,[25][26][27][28][29] Of this, ligamentous injuries (ankle sprains) account for a large proportion of occurring ankle injuries, with 62-69%. [24][25][26] More than 75% of ankle sprains involve the lateral ligaments. [24][25][26] Previous injuries and inadequate rehabilitation are considered the greatest risk factors for recurrent injuries 14,[30][31][32] : the re-injury rate of ligamentous ankle injuries in sports is increased two-to fivefold, 13,33,34 and especially in soccer up to fivefold. ...
... [24][25][26] More than 75% of ankle sprains involve the lateral ligaments. [24][25][26] Previous injuries and inadequate rehabilitation are considered the greatest risk factors for recurrent injuries 14,[30][31][32] : the re-injury rate of ligamentous ankle injuries in sports is increased two-to fivefold, 13,33,34 and especially in soccer up to fivefold. 31,[35][36][37][38][39] Persistent symptoms such as feelings of instability, persistent swelling, continuous pain conditions, limited mobility, or cartilage defects can have serious long-term consequences for athletes, and in the worst case, lead to early career dropout. ...
Article
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A literature search was conducted to systematically review and meta‐analyse time‐loss and recurrence rate of lateral ankle sprains (LAS) in male professional football players. Six electronic databases (PubMed, Scopus, Web of Science, PEDRO, CINAHL, Cochrane) were searched independently, separately both for time‐loss and recurrence from inception until 30 April 2021. In addition, reference lists were screened manually to find additional literature. Cohort studies, case reports, case‐control studies and RCT in English language of male professional football players (aged more than 16 years) for which data on time‐loss or recurrence rates of LAS were available were included. A total of 13 (recurrence) and 12 (time‐loss) studies met the inclusion criteria. The total sample size of the recurrence studies was 36.201 participants (44.404 overall initial injuries; 7944 initial ankle sprain (AS) injuries, 1193 recurrent AS injuries). 16.442 professional football players (4893 initial AS injuries; 748 recurrent AS injuries) were meta‐analysed. A recurrence rate of 17.11% (95% CI: 13.31‐20.92%; df=12; Q=19.53; I2=38.57%) based on the random‐effects model was determined. A total of 7736 participants were part of the time‐loss studies (35.888 total injuries; 4848 total ankle injuries; 3370 AS injuries). Out of the 7736 participants, 7337 participants met the inclusion criteria with a total of 3346 AS injuries. The average time‐loss was 15 days (weighted mean: 15.92; median: 14.95; min: 9.55; max: 52.9). We determined a priori considerable heterogeneity (CI: 18.15‐22.08; df=11; Q=158; I2=93%), so that the data on time‐loss are only presented descriptively. There is an average time‐loss of 15 days per LAS and a recurrence rate of 17%. LAS is one of the most common types of injury with higher recurrence rates than ACL injuries (9‐12%) in professional football players. Nevertheless, the focus of research in recent years has been mostly on ACL injuries. However, the high recurrence rates and long‐term consequences show the necessity for research in the field of LAS in elite football. Yet, heterogeneous data lead to difficulties concerning the aspect of comparability.
... 7 In a typical soccer club of around 28 players, there is an average of seven ankle injuries per season. 8 Additionally, almost 87% of ankle injuries lead to time off due to injury and the mean time off per ankle sprain is around 15 days. 8 Therefore, prevention of ankle injuries among soccer players has the potential to make large reductions in complications and healthcare and social costs; 9 for example, Marshall et al 10 found that a neuromuscular training prevention program can reduce ankle injuries by 43% and healthcare costs by Canadian $2.7 million among the Calgary soccer clubs during the season. ...
... 8 Additionally, almost 87% of ankle injuries lead to time off due to injury and the mean time off per ankle sprain is around 15 days. 8 Therefore, prevention of ankle injuries among soccer players has the potential to make large reductions in complications and healthcare and social costs; 9 for example, Marshall et al 10 found that a neuromuscular training prevention program can reduce ankle injuries by 43% and healthcare costs by Canadian $2.7 million among the Calgary soccer clubs during the season. ...
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Question: What is the effect of injury prevention programs that include balance training exercises on the incidence of ankle injuries among soccer players? Design: Systematic review of randomised trials with meta-analysis. Participants: Soccer players of any age, sex or competition level. Interventions: The experimental intervention was an injury prevention program that included balance training exercises. The control intervention was the soccer team's usual warm-up program. Outcome measures: Exposure-based ankle injury rates. Results: Nine articles met the inclusion criteria. The pooled results of injury prevention programs that included balance training exercises among 4,959 soccer players showed a 36% reduction in ankle injury per 1,000 hours of exposure compared to the control group with an injury risk ratio (IRR) of 0.64 (95% CI 0.54 to 0.77). The pooled results of the Fédération Internationale de Football Association (FIFA) injury prevention programs caused a 37% reduction in ankle injury (IRR 0.63, 95% CI 0.48 to 0.84) and balance-training exercises alone cause a 42% reduction in ankle injury (IRR 0.58, 95% CI 0.41 to 0.84). Conclusions: This meta-analysis demonstrates that balance exercises alone or as part of an injury prevention program decrease the risk of ankle injuries. PROSPERO CRD42017054450.
... A 25-player roster can expect 4.5 ankle sprains during the season. LAS accounted for the majority (75%) of the cases, followed by medial (10%) and syndesmosis sprain (5%) [8]. ...
... In interscholastic and intercollegiate competition, the average time to RTS can be as little as 24 h or up to 10 days [108]. In soccer, the RTS was on average 7 days in amateurs [19] but in professional players was 15 days (7 to 43 days) [8]. Such fast timeline is unlikely to respect the necessary physiological healing and may lead to recurrent injury. ...
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Purpose of the Review Ankle sprains are one of the most common sports injuries, resulting in sequelae that can ultimately affect function, return to play, and increase the risk of re-injury. This narrative review analyzes the scientific literature regarding acute ankle sprains in the athletic population and provides an overview of the clinical management as well as secondary prevention of this injury. Recent Findings A detailed clinical assessment is necessary to confirm diagnosis, establish the severity of the sprain, and document associated injuries. The rehabilitation program can include functional and early mobilization, manual therapy, and cryotherapy followed by a progression of strengthening, sports-specific exercises, and plyometrics. Topical and oral NSAIDs can be helpful in pain control. Return to sports should be a shared decision, encompassing both subjective and objective measures. Secondary preventive strategies should be incorporated in the treatment protocol as recurrence of this injury is common. Summary Ankle sprains are frequently seen by clinicians who care for athletes with sports injuries, particularly in the sideline and training room settings. These clinicians should be acquainted with the treatment and prevention of this condition.
... 6 Soccer players experience high rates of ankle sprain injuries and reinjuries. 36,41,42 The ankle sprain incidence in soccer is 2.52 per 1000 person-hours, 12 and the ankle sprain recurrence rate (defined as an injury of the exact nature and location involving the same player in the same season) is 9%; in contrast, the average reinjury rate for all injuries is 7%. 42 In the 2010 Fédération Internationale de Football Association (FIFA) World Cup, ankle sprain was the most common of all ankle disabilities and injuries. ...
Article
Full-text available
Background Chronic ankle instability (CAI) in soccer players can increase the risk of recurrent ankle varus sprains and damage the articular surface of the ankle joint, thus increasing the risk of osteoarthritis. It is important to understand the biomechanical characteristics of the support leg during kicking in soccer players with CAI. Purpose/Hypothesis The purpose of this study was to clarify the kinematics of the kicking motion of soccer players with CAI. It was hypothesized that at the point before ball contact when the support leg makes flat-foot contact with the ground, soccer players with CAI will land with ankle inversion in the support leg during a side-foot kick compared with players without CAI. Study Design Controlled laboratory study. Methods The study cohort included 19 male college soccer players (mean age, 20.5 ± 0.9 years) with greater than 8 years of soccer experience who were recruited from August 2019 to March 2020. Of these athletes, 10 had CAI and 9 had no CAI in the support leg, as diagnosed according to the Cumberland Ankle Instability Tool. Kinematic data for the trunk, hip, knee, and foot of the support leg during a side-foot kick were obtained using a 3-dimensional, motion-analysis system. The Mann-Whitney U test or Student t test was selected to identify differences in variables between the CAI and non-CAI groups. Results There were no significant differences in physical characteristics between the CAI and non-CAI groups. At the point when the support leg made flat-foot contact with the ground, the players with CAI had more eversion of the hindfoot with respect to the tibia (-28.3° ± 12.1° vs -13.9° ± 14.2°; P = .03), a more varus alignment of the knee (26.0° ± 10.7° vs 13.7° ± 10.5°; P = .03), and a lower arch height index (0.210 ± 0.161 vs 0.233 ± 0.214; P = .046) compared with non-CAI players. Conclusion Significant differences between players with and without CAI were seen in the support leg kinematics at flat-foot contact with the ground during the kicking cycle. Clinical Relevance The biomechanical alignment of the support leg during a side-foot kick in players with CAI may reflect a subconscious attempt to avoid inversion of the foot and further ankle sprains.
... Inversion ankle sprains, the most common injuries in sports or leisure sports (Drakos et al. 2010;Fong et al. 2007;Hootman et al. 2007;Waldén et al. 2013), frequently occur due to excessive inversion of the foot during walking, dashing, or landing from a jump (Bahr et al. 1997). Since the lateral border of the foot passes just 5 mm above the ground surface in the latter part of the swing phase during walking (Konradsen 2002a, b;Winter and Yack 1987), a subtle change in the relative position between the foot and the ground surface can lead to an inversion ankle sprain. ...
Article
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This study aimed to investigate how the cutaneous reflexes in the peroneus longus (PL) muscle are affected by changing the ankle joint position in patients with chronic ankle instability (CAI). We also investigated the correlation between the degree of reflex modulation and angle position sense of the ankle joint. The participants were 19 patients with CAI and 20 age-matched controls. Cutaneous reflexes were elicited by applying non-noxious electrical stimulation to the sural nerve at the ankle joint in the neutral standing and eversion/inversion standing positions. The suppressive middle latency cutaneous reflex (MLR; ~ 70–120 ms) and angle position sense of the ankle joint were assessed. During neutral standing, the gain of the suppressive MLR was more prominent in the CAI patients than in controls, although no significant difference was seen during 30° inversion standing. In addition, the ratios of the suppressive MLR and background electromyography in a neutral position were significantly larger than those at the 15°, 25°, and 30° inversion positions in CAI patients. No such difference was seen in control individuals. Furthermore, the correlations between reflex modulation degree and position sense error were quite different in CAI patients compared to controls. These findings suggest that the sensory-motor system was deteriorated in CAI patients due to changes in the PL cutaneous reflex pathway excitability and position sense of the ankle joint.
... Professional footballers are at high risk of sports-related injuries, including those to the head, thigh, knee and foot/ankle. 1 Over the past 25 years, the prevalence of injuries to the thigh (23%-26%), foot/ankle (20%-23%) and knee (14%-18%) has consistently been reported to be the three most common injury sites in professional football. [2][3][4][5][6] A study of one English Premier League club found that over a 4-season period, 20% of all injuries involved the foot/ankle with a mean return to play time of 54 days. 7 Injuries to the ankle lateral ligament complex, particularly the anterior talofibular ligament, were most frequent, accounting for 31% of all foot/ankle injuries. ...
Article
Full-text available
Introduction Professional footballers commonly experience sports-related injury and repetitive microtrauma to the foot and ankle, placing them at risk of subsequent chronic pain and osteoarthritis (OA) of the foot and ankle. Similarly, repeated heading of the ball, head/neck injuries and concussion have been implicated in later development of neurodegenerative diseases such as dementia. A recent retrospective study found that death from neurodegenerative diseases was higher among former professional soccer players compared with age matched controls. However, well-designed lifetime studies are still needed to provide evidence regarding the prevalence of these conditions and their associated risk factors in retired professional football players compared with the general male population. Objectives To determine whether former professional male footballers have a higher prevalence than the general male population of: (1) foot/ankle pain and radiographic OA; and (2) cognitive and motor impairments associated with dementia and Parkinson’s disease. Secondary objectives are to identify specific football-related risk factors such as head impact/concussion for neurodegenerative conditions and foot/ankle injuries for chronic foot/ankle pain and OA. Methods and analysis This is a cross-sectional, comparative study involving a questionnaire survey with subsamples of responders being assessed for cognitive function by telephone assessment, and foot/ankle OA by radiographic examination. A sample of 900 adult, male, ex professional footballers will be recruited and compared with a control group of 1100 age-matched general population men between 40 and 100 years old. Prevalence will be estimated per group. Poisson regression will be performed to determine prevalence ratio between the populations and logistic regression will be used to examine risk factors associated with each condition in footballers. Ethics and dissemination This study was approved by the East Midlands-Leicester Central Research Ethics Committee on 23 January 2020 (REC ref: 19/EM/0354). The study results will be disseminated at national and international meetings and submitted for peer-review publication.
... 5 In addition, approximately 60% of ankle sprains in athletes happen due to contact or direct trauma, with an ankle re-injury rate in contact sport between 4 and 29%. 6,7 Ankle sprains often result in tears of the lateral collateral ligaments (i.e. anterior talofibular ligament and calcaneofibular ligament) and related muscle-tendinous structures, thereby negatively affecting proprioceptive function of the mechano-receptors. ...
Article
Background: Ankle sprain is the most common type of sports injury, especially in team sports. Standing and dynamic landing balance, as an indicator of ankle instability, were investigated using varying experimental approaches. Methods: In the present cross-sectional study, 81 adolescent female elite handball and football players were divided into two groups based on previous ankle sprain injury (PI) or not (C). At time of test, all players were fully returned to elite-level sport. Subjects were tested during a one-legged landing (OLL) and in a one-legged static standing balance test (OLBT). In the OLL CoP trajectory displacement was calculated in 200 ms time epochs for evaluation of the initial stages of dynamic landing balance. OLBT was evaluated by calculating total displacement of the CoP trajectory. Results: CoP displacement was greater in PI than C during the first 200 milliseconds epoch after landing (p = 0.001, 252 mm (44), vs. 223 mm (28), respectively) and in the subsequent 200 ms epoch (p = 0.021, 72 mm (20), vs. 61 mm (16), respectively). No significant differences between PI and C were observed in time epochs from 400 to 1000 milliseconds or in OLBT. Conclusions: Adolescent elite athletes with a history of previous ankle sprain demonstrate impaired one-legged landing balance in the first 400 milliseconds following jump landing compared to noninjured controls. Consequently, although athletes with previous ankle sprain may return to sport, dynamic postural control may not be fully restored. Future prospective studies are needed to decide, if the OLL test could be considered a relevant criterion tool for safe return-to-sport.
... The average time to return to sport after lateral ankle sprain is 16 to 24 days [5,[11][12][13][14][15], but a large proportion of athletes experience re-injury or other long-term problems [1,4,[16][17][18][19][20][21]. Epidemiology data of recurrent ankle sprains in athletes range from 12% to 47%, with the largest re-injury rates occurring in junior basketball (47%), volleyball (46%) and American Football (43%) [22]. ...
Article
Full-text available
Research questions: 1) Do exercise-based rehabilitation programs reduce re-injury following acute ankle sprain?; 2) Is rehabilitation effectiveness moderated by the exercise's therapeutic quality, content and volume? Methods: This systematic review with meta-analysis (PROSPERO: CRD42020210858) included randomized controlled trials in which adults who sustained an acute ankle sprain received exercise-based rehabilitation as an intervention. Databases CINAHL, Web of Science, SPORTDiscus, Cochrane Central Register of Controlled Trials, PEDro and Google Scholar were searched for eligible articles (last search: March 2021). ROB II screening tool by Cochrane was used to assess risk of bias and the i-CONTENT tool was used to assess quality of interventions. Both qualitative analysis and quantitative data synthesis were performed. Results: Fourteen randomized controlled trials comprising 2182 participants were included. Five studies were judged overall low risk of bias and i-CONTENT assessment showed poor to moderate therapeutic quality of exercise across all included articles. Pooled data found significant reductions in re-injury prevalence at 12 months, in favour of the exercise-based rehabilitation group vs usual care (OR: 0.60; 95%CI: 0.36 to 0.99). Pooled data for re-injury incidence showed not-significant results (MD: 0.027; 95%CI: -2.14 to 2.19). Meta-regression displayed no statistically significant association between training volume and odds of re-injury (r = -0.00086; SD: 0.00057; 95%CI: -0.00197 to 0.00025). Results from patient-reported outcomes and clinical outcomes were inconclusive at 1 month, 3-6 months and 7-12 months of follow up. Conclusion: Exercise-based rehabilitation reduces the risk of recurrent ankle sprain compared to usual care, but there is insufficient data to determine the optimal content of exercise-based interventions. Training volume varied considerably across studies but did not affect the odds of sustaining a re-injury. Effects on patient-reported outcomes and clinical outcomes are equivocal. Future research should compare different exercise contents, training volumes and intensities after ankle sprain.
... In addition to various fractures of the ankle joint, w5% of all distortion traumas become chronic, with corresponding clinical symptoms. [1][2][3][4][5] The present study refers exclusively to anterior ankle impingement. Typical anterior ankle impingement is caused by the repeated forced impact of the tibial crest against the neck of the talus or the soft tissue, resulting in the formation of scar tissue, which become impacted. ...
Article
Full-text available
Purpose The purpose of the study was to investigate the added value of electrothermal denervation (ETD) in arthroscopic debridement of anterior ankle impingement. Methods Between May 2019 and December 2020, 58 patients who received arthroscopic anterior decompression for the impingement of the anterior tibiotalar joint were randomized to Group A (n = 29) with ETD of synovial and capsular tissue of the ankle and Group B (n = 29) without ETD. Patients included 37 men and 21 women, with a mean age of 42 years. The pain, range of motion (ROM), and function were recorded using the visual analog scale foot and ankle (VAS FA), the Foot Function Index (FFI), and the American Orthopaedic Foot and Ankle Society Score (AOFAS), both preoperatively and postoperatively. Results Twenty-four hours after surgery, the pain level at rest using the VAS (worst 10 points) was 3.8 points on average (Group A: 3.7, Group B: 3.9). After 6 weeks, the mean VAS FA was 62.6 points, and ROM improved by an average of 9.1° (Group A: 9.8°, Group B: 8.6°; P > .05), the mean FFI was 40.4 points (Group A: 37.8, Group B: 42.8), the mean AOFAS was 73.1 points (Group A: 71.3, Group B: 75.1). All postoperative scores improved significantly compared with preoperative scores. No significant differences were observed between groups. Conclusions The hypothesis of pain reduction with the use of ETD was refuted. The addition of ETD as part of the arthroscopic debridement of the anterior ankle impingement did not show any significant superiority in terms of the collected scores (VAS-FA, FFI, and AOFAS) at 24 hours and 6 weeks after the surgery and resulted in a comparable length of stay in the hospital and incapacity to work.
Article
Purpose To study the epidemiology and return to play characteristics of anterior and posterior ankle impingement syndromes (AAIS and PAIS) over 18 consecutive seasons in male professional soccer players. Methods Between the 2001–2002 and 2018–2019 seasons, 120 European soccer teams were followed prospectively for various seasons. Time loss injuries and player exposures were recorded individually in 6754 unique players. Injury incidence and burden were reported as the number of injuries and days absence per 1000 h with 95% confidence intervals (CIs). Injury severity was reported as median absence in days with the interquartile range (IQR). Results Out of 25,462 reported injuries, 93 (0.4%) were diagnosed as AAIS (38%) or PAIS (62%) in 77 players. AAIS and PAIS were similar regarding injury characteristics except for a greater proportion of AAIS having a gradual onset (69% vs.47%; P = 0.03) and being re-injuries (31% vs. 9%; P = 0.01). Impingement syndromes resulted in an overall incidence of 0.03 injuries (95% CI 0.02–0.03) per 1000 h and an injury burden of 0.4 absence days per 1000 h. PAIS incidence was significantly higher than that for AAIS [0.02 (95% CI 0.002–0.03) vs. 0.01 (95% CI 0.005–0.01) injuries per 1000 h (RR = 1.7). The absence was significantly longer in AAIS than in PAIS [10 (22) vs. 6 (11) days; P = 0.023]. Impingement syndromes that presented with a gradual onset had longer absences in comparison to impingement with an acute onset [8 (22) vs. 5 (11) days; P = 0.014]. Match play was associated with a higher incidence and greater injury burden than training: 0.08 vs. 0.02 injuries per 1000 h (RR 4.7), respectively, and 0.9 vs. 0.3 days absence per 1000 h (RR 2.5). Conclusion Ankle injuries are frequent in men’s professional soccer and ankle impingement is increasingly recognized as a common source of pain, limited range of motion, and potential time loss. In our study, ankle impingement was the cause of time loss in less than 0.5% of all injuries. PAIS was more frequently reported than AAIS, but AAIS was associated with more absence days and a higher re-injury rate than PAIS. The findings in this study can assist the physician in best practice management on ankle impingment syndromes in professional football. Level of evidence II.
Article
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Limited information is available on the variation in injury rates over multiple seasons of professional football. To analyse time-trends in injury characteristics of male professional football players over 11 consecutive seasons. A total of 1743 players comprising 27 teams from 10 countries were followed prospectively between 2001 and 2012. Team medical staff recorded individual player exposure and time loss injuries. A total of 8029 time loss injuries were recorded. The match unavailability due to injury was 14% and constant over the study period. On average, a player sustained two injuries per season, resulting in approximately 50 injuries per team and season. The ligament injury rate decreased during the study period (R(2)=0.608, b=-0.040, 95% CI -0.065 to -0.016, p=0.005), whereas the rate of muscle injury (R(2)=0.228, b=-0.013, 95% CI -0.032 to 0.005, p=0.138) and severe injury (R(2)=0.141, b=0.015, 95% CI -0.013 to 0.043, p=0.255) did not change over the study period. In addition, no changes in injury rates over the 11-year period were found for either training (R(2)=0.000, b=0.000, 95% CI -0.035 to 0.034, p=0.988) or match play (R(2)=0.282, b=-0.015, 95% CI -0.032 to 0.003, p=0.093). The injury rate has decreased for ligament injuries over the last 11 years, but overall training, match injury rates and the rates of muscle injury and severe injury remain high.
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Ankle injuries are common occurrences in athletics involving and requiring extreme ranges of motion. Ankle sprains specifically occur with a 1 in 10 000 person rate in active individuals each day. If trauma is repetitive, the ankle structures have potential to experience secondary injury and dysfunction. Included in this category of dysfunction are both anterior and posterior ankle impingement syndromes where disruption of the bony structures, joint capsule, ligaments, and tendons typically occurs. Ankle impingement is described as ankle pain that occurs during athletic activity, with recurrent, extreme dorsiflexion or plantar flexion with the joint under a load. Ankle impingements can be classified according to what structures become involved both anteriorly and posteriorly. Osseous impingement, soft tissue impingement, impingement of the distal fascicle of anterior inferior tibiofibular ligament, and meniscoid lesions are all documented causes of ankle impingement. These changes tend to be brought about and exacerbated by extreme ranges of motion. Understanding various impingement types will better enable the clinician to prevent, identify, treat, and rehabilitate affected ankles. Acknowledging activities that predispose to ankle impingement syndrome will enhance prevention and recovery processes. Description of ankle impingement etiology and pathology is the objective of the current review. Level of Evidence: Therapeutic, Level IV
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Variations in definitions and methodologies have created differences in the results and conclusions obtained from studies of football (soccer) injuries, making interstudy comparisons difficult. Therefore an Injury Consensus Group was established under the auspices of Fédération Internationale de Football Association Medical Assessment and Research Centre. A nominal group consensus model approach was used. A working document on definitions, methodology, and implementation was discussed by the group. Iterative draft statements were prepared and circulated to members of the group for comment before the final consensus statement was produced. Definitions of injury, recurrent injury, severity, and training and match exposures in football together with criteria for classifying injuries in terms of location, type, diagnosis, and causation are proposed. Proforma for recording players’ baseline information, injuries, and training and match exposures are presented. Recommendations are made on how the incidence of match and training injuries should be reported and a checklist of issues and information that should be included in published reports of studies of football injuries is presented.
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