Physician's Playbook

Dr. Sergio Ulloa, DO

Our mobility is something we all take for granted until we can’t walk or run well. When it comes to our feet and ankles, any injury to that region of ligaments, tendons or tissue has the potential to stop us in our tracks and affect our way of life.

In sports — where speed, agility and physical contact are critical to the game — a foot or ankle ailment essentially becomes a game-changer, especially if the injured player isn’t removed from the game. Unlike other types of nagging pain where a player may attempt to play through the pain, foot and ankle pain is often noticeable by the way the player walks (their gait), speed off the line, lateral movement or cuts, and their ability to gain leverage in the case of physical contact. Any foot or ankle pain along with any visual hobbling is a sign to athletes, coaches and trainers that, no matter how minor or serious, athletes should get evaluated and receive some level of treatment.

Tough breaks and hard sprains

When it’s obvious that things aren’t going our way, some might suggest we’ve experienced a tough break. A broken ankle is both obvious and a tough break. Athletes understand that injury and know that they will be sidelined indefinitely until the bones heal. However, many of those injuries can be treated without surgery in a cast or walking boot.

Ankle and foot pain that isn’t an obvious bone break is harder for athletes to wrap their heads around, especially when the season is here and they want to compete. I will address four common foot and ankle injuries and how best to address them, including lateral and high ankle sprains, Achilles tendon rupture and plantar fasciitis.

Lateral sprain

If you’ve ever “rolled” or “twisted” your ankle, you’ve experienced the most common form of ankle injury — the lateral sprain. It occurs when the ankle suddenly becomes unstable and pushes outward after the foot has been planted on the ground. It can happen at any time, with or without contact, while walking, running or jumping. A lateral sprain is an injury to the lateral ligaments on the outside of the ankle that help to hold it place and stabilize joints. Those ligaments are like rubber bands that hold bones together. When stretched beyond capacity, they become strained and can tear.

The typical symptoms of any ankle sprain can include pain, swelling, potential bruising and difficulty moving the ankle. A minor twist of the ankle can be treated at home with rest and ice, but any prolonged pain requires diagnosis and treatment. Physicians grade all ligament sprains on a scale from 1 to 3, ranging from mild sprain to complete tear. A Grade 1 sprain is a mild sprain of stretched ligaments. The joint remains stable and the individual can usually walk with limited pain. Grade 1 sprains won’t sideline athletes for any significant length of time. However, rehabilitation exercises, ankle taping, support bracing, and over-the-counter pain medication can help the recovery process. Many of us have experienced grade 1 sprains, and those resolve well with time.

Grade 2 sprains are moderate sprains where pain is much more severe, the ability to walk is compromised, and applying pressure becomes nearly intolerable. These represent symptoms of a partial ligament tear. Grade 3 sprains represent ligaments that have been torn from the bone or torn completely. This is the only sprain that may require surgical repair. Grade 3 injuries also cause instability, as the ligament can’t hold the bones in place, which makes walking, or any motion much more painful. Recovery time varies by athlete for any type of lateral sprain, but adhering to a physician’s recovery plan will help athletes return without lingering effects. These are the most frustrating sprains is that athletes will try to push the envelope to get back sooner. The problem is they can easily reinjure the ligament stalling their return to sport.

High ankle sprain

These are ligaments above the ankle joint and between the tibia and fibula leg bones that keep those bones from spreading to far apart. Collectively, these bones and ligaments are known as the syndesmosis, and when it experiences trauma from twisting or rotating, a high ankle sprain is the outcome. A common scenario is when a player’s ankle is twisted or body weight from another player forces movement while the foot is still firmly planted. Typically a high ankle sprain has a longer recovery time and may require a stabilizing walking boot or surgery to help with recovery.

Recently New York Giants running back Saquon Barkley endured a high ankle sprain in the third week of the NFL season with the expectation of missing several weeks. Yet after only two weeks Barkley is practicing and could see action after missing only three games when recovery is typically in the four to eight week range. For those not as fortunate to bounce back like Barkley, advancements have been made in a surgical procedure known as the “tightrope” technique. This minimally invasive surgery threads a pin into the syndesmosis to hold the bones in place without the use of screws and helps athletes achieve an accelerated recovery. While tightrope surgery is not necessary for all sprains it can help return athletes back to the field faster if needed.

Plantar fasciitis

The recurring story we hear from athletes is how the get out of bed and start walking like a 90-year-old due to heel pain for a few minutes reveals a classic case of plantar fasciitis. This nagging injury occurs when the band of tissue that connects the heel to the toes, and gives form to the arch along the sole of the foot, becomes inflamed. The pain is felt near the heel and often emerges after periods of rest versus during physical exertion. The timing of pain flare-ups can have athletes believing it’s not sports-related. However, playing through the pain will only prolong or worsen the injury.

Plantar fasciitis can occur in all types of athletes, can stem from high levels of exertion and overuse, and can emerge in players bearing excessive weight on their feet. Athletes with flat feet as well as those with high arches are prone to plantar fasciitis and can benefit from the proper footwear, whether that’s in the type of shoe or through inserts.

When an athlete experiences plantar fasciitis, rest, stretching of the plantar fascia and Achilles, and soft tissue massage all help in rehabilitation. Athletes might also ice the affected heel or use ibuprofen for pain relief. Most people affected by plantar fasciitis see significant improvement within two months of treatment. However, it is a stubborn injury that can take up to a year to completely heal.

Achilles tendon rupture

When the tendon that connects the calf muscles to the heel bone tears and fully separates, athletes have a season-ending injury known as an Achilles tendon rupture. It typically requires surgery. It is immediately noticeable by its snapping sound and the resulting pain in the back of the ankle and calf, and can result from contact or noncontact activity. It can feel as though someone kicked them in the calf and it’s not uncommon for them to look around for a culprit when they sustain an Achilles injury.

One of the best ways to stave off this injury is to take stretching seriously. Stretching the muscles and pre-activity warm-ups are way to loosen up muscles, ligaments and tendons for the activity to come. Regardless if surgery is necessary, when an Achilles tendon ruptures the ankle will need to be immobilized in a cast and can take up to six months to heal with physical therapy. Athletes should expect a full year to return to normal.

Foot and ankle injuries can trip up athletes from achieving their goals. However, stretching and proper conditioning can go a long way to help prevent some of these injuries. When injuries do occur, immediately applying the RICE protocol — rest, ice, compression and elevation — will reduce swelling and avoid additional damage until a physician can diagnosis the extent of the injury.

Bottom line: don’t let foot and ankle pain lead to something worse. If it hurts, get off your feet and get a diagnosis. It’s the first good step to help you get back in the game.

Dr. Ulloa, of OhioHealth Physician Group Heritage College, is a native of Athens who graduated from Ohio University medical school. During a fellowship at the Cleveland Clinic, he served as an assistant team physician for the Browns, Indians and Cavaliers, went to spring training with the Indians and attended the National Football League Scouting Combine in Indianapolis. He presently is a board-certified orthopedic surgeon for the Ohio University Athletic Department.

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