Ankle sprains in field hockey players: is it possible despite wearing a skate?

Ankle sprains are not the first injury to come to mind when talking about potential field hockey injuries. It’s true that the classic lateral sprain seen in basketball and soccer, among others, is uncommon in field hockey, mainly because of the skate. However, the distal tibiofibular (TFD) sprain, also known as the high, mortise or syndesmotic sprain, is very common in field hockey. In a 2004 study of professional players from the St. Louis Blues and Dallas Stars, there were 5 lateral ankle sprains for every 14 TFD sprains that season (1). This type of sprain affects the ligament connecting the 2 leg bones, the tibia and fibula, located on the front and side of the ankle.

Injury mechanism

TFD sprains usually occur when the ankle is forced into external rotation (2). There are several possible explanations for this movement:
– The athlete pivots inwards, but the foot remains planted on the ground.
– Contact with another player causes the knee to move inwards while the foot remains planted on the ground.
– A fall on the leg with the foot stuck in external rotation towards the ground

In field hockey, the skate is a risk factor for this type of injury, given the limited movement allowed by the skate to absorb the impact and the high risk of collision associated with the sport.

Evaluation

Signs and symptoms of TFD sprain include:
– Inability or great difficulty putting weight on the affected ankle
– Increased pain with ankle movements, especially dorsal flexion (bringing the foot towards the body)
– Pain on palpation of the anterior tibiofibular ligament
– Variable degree of swelling, depending on the severity of associated injuries such as fractures or nearby ligament damage

There are many tests that can verify the hypothesis of such a sprain, but they are not very reliable. The Kleiger test, a passive movement of dorsal flexion and external rotation of the ankle while stabilizing the distal part of the tibia and fibula, is frequently used to guide the diagnosis. Functional tests such as walking, jumping and taping to stabilize the TFD region during active ankle movements, in addition to the mechanism of injury, are other tools that can be used to complete the information needed to determine whether or not the TFD ligament has been damaged.

Treatment (2)

1. Acute phase
This phase consists of protecting the ankle, minimizing pain, inflammation, muscle atrophy and loss of mobility. Compressive taping, mobility exercises, gentle strengthening and ice are the tools used in this phase. Crutches are often used for a period of 2 weeks without putting the foot on the ground, to ensure that the ligament heals properly. When the player is able to put his weight painlessly on his ankle without crutches, he moves on to the next phase.

2. Sub-acute phase
This phase consists of normalizing the player’s mobility, strength and general function. More advanced mobility, strengthening and proprioception/balance exercises are given and must be performed painlessly. Swimming and other transfer activities can be useful for increasing cardiovascular capacity. When the player can jog and jump without pain, he progresses to the next phase.

3. Advanced phase
This phase involves preparing for the return to sport. Slow-to-fast, plyometric and sport-specific agility exercises on different surfaces should be added before returning to sport. This can be done when the player can perform sport-specific movements with good control, with little or no pain or feeling of instability.

DFT sprains take longer to rehabilitate than lateral sprains. On average, DFT sprains last 6 to 8 weeks, compared with an average of 3 to 4 weeks for lateral sprains (1). This important point begs the question: how can ankle sprains be prevented? An interesting study by McGuine TA and colleagues shows that balance training may have a beneficial effect on the incidence of sprains (3).

Although the guidelines presented above are usually used for the treatment of TFD sprains, it should be tailored to the individual according to his or her goals, the clinical presentation of the condition and his or her physical capabilities. A medical professional is essential to monitor the injury and ensure the athlete’s progress through the various phases of rehabilitation.

Written by Ève Poisson, M.Physiotherapy

 References:

(1) Wright RW, Barile RJ, Surprenant DA, Matava MJ. Ankle syndesmosis sprains in national field hockey league players. Am J Sports Med. 2004 :32(8) :1941-1945.
(2) Williams GN, Allen EJ. Rehabilitation of syndesmotic (high) ankle sprains. Sage Journals. 2010 :2(6) :460-470.
(3) McGuine TA, Greene JJ, Joe J, Thomas G, Leverson G. Balance As a Predictor of Ankle Injuries in High School Basketball Players. Clin Jour Sports Med. 2000 :10(4) :239-244.