The epidemiology of ankle injuries in professional rugby union players

A high incidence of injury among male university student rugby players requires urgent injury prevention strategies

OBJECTIVES

Determine the epidemiology and clinical characteristics of training and match injuries in university student rugby players over a two-season period.

DESIGN

Prospective cohort.

SETTING

Varsity Cup (VC) and Young Guns (YG) rugby tournaments (2018 and 2019).

PARTICIPANTS

171 male university student rugby players.

MAIN OUTCOME MEASURES

For time-loss injuries: injury incidence (injuries per 1000 player-hours), injured player proportion (% of injured players) and the frequency (n, %) of injury characteristics (new or recurrent, anatomical region, body area, severity.

RESULTS

The injury incidence was 2.4 per 1000 player-hours for training injuries and 131.1 per 1000 player-hours for match injuries. The overall injured player proportion was 59.6%. New injuries (83.9%) were more frequent than recurrent injuries. Most injuries occurred in the lower limb involving muscle/tendon (56.7%) and ligament/joint capsule (27.2%). The shoulder (19.6%) and ankle (15.7%) were the most common body areas of injury during matches and training, respectively.

CONCLUSIONS

There was a high injured player proportion and match injury incidence among university student rugby players. Most injuries were new. Lower limb injuries were most common in training whereas upper limb injuries were most common in matches. These findings highlight the need to prioritise future injury prevention among university student rugby players.

Successful Return to Sport and Daily Activities After Suture Augmentation of Both the Anterior Talofibular Ligament and Calcaneofibular Ligament

Purpose

To evaluate the return to sport and daily activities in addition to clinical outcomes after modification of the Brostöm repair, specifically using suture augmentation for concomitant fixation of both the anterior talofibular ligament and calcaneofibular ligament.

Methods

Patients who had grade III ankle sprains and lateral ankle instability, all of whom failed supervised conservative management, were included. Patients underwent a modified Broström procedure consisting of suture augmentation for both the anterior talofibular ligament and calcaneofibular ligament. For clinical outcome evaluation, Foot and Ankle Ability Measure (FAAM) and Karlsson-Peterson Scoring System for Ankle Function questionnaires coupled with questions regarding time of return to sport and level of sports activity were used.

Results

Thirty-one patients were included. The differences in preoperative and postoperative FAAM scores for both the Activities of Daily Living subscale and Sports subscale were significant (P < .001). The FAAM Activities of Daily Living score improved from an average of 46.06 preoperatively to 77.49 postoperatively (P < .001, 99% confidence interval, 26.4-36.4). The FAAM Sports score improved from an average of 4 preoperatively to 19.31 postoperatively (P < .001, 99% confidence interval, 11.6-19.0). For the Karlsson-Peterson Scoring System for Ankle Function, the surveyed population reported a mean of 82.74 points out of 100 post-op (standard deviation 20.14). The mean time to return to sport activity was 5.72 months. Mean follow-up time was 24.12 months.

Conclusions

This variant Broström procedure with suture anchors and augmentation of both the anterior talofibular ligament and calcaneofibular ligament was effective in helping patients return to their preinjury functionality level in both daily life and sports activity.

Level of Clinical Evidence

Level IV, therapeutic case series.

Treatment of Intra-Articular Lesions After Posterior Inferior Tibiofibular Ligament Injury: A Case Series of Elite Rugby Players

Background

Surgical intervention is not typically used to treat symptoms after mild tibiofibular ligament injuries without ankle dislocation or subluxation.

Purpose

To describe outcomes in patients arthroscopically treated for unique intra-articular lesions after sustaining syndesmosis injury of the ankle.

Study Design

Case series; Level of evidence, 4.

Methods

A total of 11 elite male rugby players with a mean age of 21.0 years (range, 17-28 years) were referred to our hospital for prolonged posterior ankle pain after a high ankle sprain during rugby football. The patients were examined using standing view radiography, computed tomography (CT) and magnetic resonance imaging (MRI) to determine the extent of ligament damage. Posterior ankle arthroscopy was performed to examine intra-articular lesions. The patients were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle/hindfoot rating scale and sports activity score of the Self-Administered Foot Evaluation Questionnaire (SAFE-Q).

Results

The average reduced tibiofibular overlap on the standing mortise view was 1.2 mm (range, 0.5-2.0 mm) compared with the opposite ankles. Mason type 1 fracture was detected on CT in 6 patients, and ossification of the interosseous membrane was detected in 2 patients. A bone bruise in the posterior malleolus was observed on MRI in all but 1 patient. Intra-articular fragments located in the posterior ankle were observed and removed arthroscopically. Symptoms improved rapidly after arthroscopic treatment in all patients. All patients returned to rugby games at a median of 11 weeks postoperatively. The median AOFAS scores improved from 77 preoperatively to 100 postoperatively (P < .01), and the median SAFE-Q sports activity subscale score improved from 49.4 to 100 (P < .01).

Conclusion

All unique intra-articular lesions that developed in rugby football players after syndesmosis injury were able to be treated arthroscopically. Patients returned to playing rugby football without syndesmosis reduction. Posterior ankle arthroscopy was effective in patients with residual symptoms after syndesmosis injury.

Effect of different ankle braces on lower extremity kinematics and kinetics following special-induced fatigue for volleyball players with functional ankle instability

Background

The aim of this study is to examine the effects of different ankle braces on functional ankle instability (FAI) participants following special-induced fatigue, which will provide advice for preventing ankle sprains in volleyball game.

Methods

A total of 18 male collegiate volleyball players with FAI were recruited. The kinematics and kinetics data were acquired from the participants during single-leg drop landing using the infrared motion capture system (Mars2H, Nokov, China) and the force platform (Bertec, USA). A 2 × 2 within subjects design ANOVA was adopted to analyze the data.

Results

Whether fatigue or not, soft and semi-rigid brace reduced the ankle inversion (P = 0.025). Moreover, soft brace reduced the sagittal range of motion (ROM) of the ankle joint before fatigue (P = 0.05). In addition, the semi-rigid brace shortened the time to stability in the medial and lateral directions (P = 0.039) as well as the vertical directions (P < 0.001). The semi-rigid brace reduced the ground reaction force post-fatigue (P = 0.001).

Conclusion

Soft ankle brace reduced the sagittal range of motion pre-fatigue. Since volleyball requires athletes to jumping and landing repeatedly, and the ankle sagittal ROM was an important cushion during landings. Thus, soft ankle brace might result in overuse injury for lower extremity. However, the semi-rigid ankle brace increased the dynamic stability in the medial and vertical directions, and reduced the ankle inversion angle and forward ground reaction force post-fatigue. This ensured that the volleyball player's ankle was in a neutral position during landing, reducing the risk of excessive inversion caused by contact with the opposing player during spike and block.

Accuracy of radiographic techniques in detection of the calcaneofibular ligament calcaneal insertion for lateral ankle ligament complex surgery

BACKGROUND

Grade III ankle sprains that fail conservative treatment can require surgical management. Anatomic procedures have been shown to properly restore joint mechanics, and precise localization of insertion sites of the lateral ankle complex ligaments can be determined through radiographic techniques. Ideally, radiographic techniques that are easily reproducible intraoperatively will lead to a consistently well-placed CFL reconstruction in lateral ankle ligament surgery.

PURPOSE

To determine the most accurate method to locate the calcaneofibular ligament (CFL) insertion radiographically.

METHODS

MRIs of 25 ankles were utilized to identify the "true" insertion of the CFL. Distances between the true insertion and three bony landmarks were measured. Three proposed methods (Best, Lopes, and Taser) for determining the CFL insertion were applied to lateral ankle radiographs. X and Y coordinate distances were measured from the insertion found on each proposed method to the three bony landmarks: the most superior point of the postero-superior surface of the calcaneus, the posterior most aspect of the sinus tarsi, and the distal tip of the fibula. X and Y distances were compared to the true insertion found on MRI. All measurements were made using a picture archiving and communication system. The average, standard deviation, minimum, and maximum were obtained. Statistical analysis was performed using repeated measures ANOVA, and a post hoc analysis was performed with the Bonferroni test.

RESULTS

The Best and Taser techniques were found to be closest to the true CFL insertion when combining X and Y distances. For distance in the X direction, there was no significant difference between techniques (P = 0.264). For distance in the Y direction, there was a significant difference between techniques (P = 0.015). For distance in the combined XY direction, there was a significant difference between techniques (P = 0.001). The CFL insertion as determined by the Best method was significantly closer to the true insertion compared to the Lopes method in the Y (P = 0.042) and XY (P = 0.004) directions. The CFL insertion as determined by the Taser method was significantly closer to the true insertion compared to the Lopes method in the XY direction (P = 0.017). There was no significant difference between the Best and Taser methods.

CONCLUSION

If the Best and Taser techniques can be readily used in the operating room, they would likely prove the most reliable for finding the true CFL insertion.

Injury Trends for School Rugby Union in Ireland: The Need for Position-specific Injury-prevention Programs

BACKGROUND

Concern has been raised over the injury risk to school Rugby union (Rugby) players and the potential long-term health consequences. Despite the increase in studies for this cohort, the influence of playing position on injury incidence and presentation is unclear.

PURPOSE

To describe the incidence, nature and severity of match injuries for school Rugby in Ireland overall, and as a function of playing position.

STUDY DESIGN

Prospective cohort study.

METHODS

Data were collected from 15 male (aged 16-19 years) school Senior Cup teams across 2 seasons. In total, 339 players participated in season 1, whereas 326 players participated in season 2. Injury data were recorded onto a bespoke online platform. Match exposure was also recorded.

RESULTS

The incidence rate of match injuries (24-hour time loss) was 53.6 per 1000 hours. Across both seasons, 6810 days were lost from play due to injury. Forwards (65.4 per 1000 hours) sustained significantly more (P < 0.05) injuries than backs (40.5 per 1000 hours). The head, shoulder, knee, and ankle were the most common injured body regions; however, forwards sustained significantly more (P < 0.05) head and shoulder injuries than backs. The tackle was responsible for the majority of injuries in both groups. The highest proportion of injuries occurred during the third quarter.

CONCLUSION

Clear differences in injury presentation and incidence were evident when comparing forwards versus backs. The high rate of head and shoulder injuries in the forwards suggest the need for more targeted injury-prevention strategies and further research on education and laws around the tackle event. The spike of injuries in the third quarter suggests that fatigue or inadequate half-time warm-up may be a contributing factor warranting further exploration.

CLINICAL RELEVANCE

This study demonstrates clear differences in injury presentation according to playing position in school Rugby and highlights the need for a more tailored approach to the design and implementation of injury-prevention strategies.

LEVEL OF EVIDENCE

Level 3.

Return to Play and Player Performance After Achilles Tendon Rupture in UEFA Professional Soccer Players: A Matched-Cohort Analysis of Players From 1999 to 2018

Background:

Achilles tendon rupture (ATR) is a potentially career-ending injury in professional athletes. Limited information exists regarding return to play (RTP) in professional soccer players after this injury.

Purpose:

To determine the RTP rate and time in professional soccer players after ATR and to evaluate player performance relative to matched controls.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We evaluated 132 professional soccer players who suffered an ATR between 1999 and 2018. These athletes were matched 2:1 to uninjured controls by position, age, season of injury, seasons played, and height. We collected information on the date of injury, the date of RTP, and player performance metrics (minutes played, games played, goals scored, assists made, and points per game) from official team websites, public injury reports, and press releases. Changes in performance metrics for the 4 years after the season of injury were compared with metrics 1 season before injury. Univariate comparisons were performed using independent-sample, 2-group t tests and Wilcoxon rank-sum tests when normality of distributions was violated.

Results:

The mean age at ATR was 27.49 ± 4.06 years, and the mean time to RTP was 5.07 ± 2.61 months (18.19 ± 10.96 games). The RTP rate was 71% for the season after injury and 78% for return at any timepoint. Overall, 9% of the injured players experienced a rerupture during the study period. Compared with controls, the injured players played significantly less (-6.77 vs -1.81 games [P < .001] and -560.17 vs -171.17 minutes [P < .05]) and recorded fewer goals (-1.06 vs -0.29 [P < .05]) and assists (-0.76 vs -0.02 [P < .05]) during the season of their Achilles rupture. With the exception of midfielders, there were no significant differences in play time or performance metrics between injured and uninjured players at any postinjury timepoint.

Conclusion:

Soccer players who suffered an ATR had a 78% RTP rate, with a mean RTP time of 5 months. Injured players played less and demonstrated inferior performance during the season of injury. With the exception of midfielders, players displayed no significant differences in play time or performance during any of the 4 postinjury seasons.

Association between lower extremity muscle strength and acute ankle injury in youth team-sports athletes

OBJECTIVES

To investigate lower extremity muscle strength as risk factor for an acute ankle injury in youth athletes.

DESIGN

Cohort study.

SETTING

Basketball and floorball clubs.

PARTICIPANTS

188 youth (≤21) male and 174 female athletes.

MAIN OUTCOME MEASURES

1RM leg press, maximal concentric isokinetic quadriceps and hamstrings as well as maximal isometric hip abductor strength were measured and athletes were followed for an acute ankle injury up to three years. Cox regression models were used in statistical analyses.

RESULTS

In males, greater 1RM leg press and maximal quadriceps strength increased the risk of any type of acute ankle injury (Hazard ratio [HR] for 1 SD increase, 1.63 [95% CI, 1.12-2.39] and 1.43 [95% CI, 1.01-2.01], respectively). In females, greater 1RM leg press and difference between legs in hip abduction strength increased the risk of acute non-contact ankle injury (HR for 1 SD increase, 1.44 [95% CI, 1.03-2.02] and 1.44 [95% CI, 1.03-2.00], respectively). However, ROC curve analyses showed AUC:s of 0.57-0.64 indicating "fail" to "poor" combined sensitivity and specifity of these tests.

CONCLUSION

Greater strength in both sexes along with asymmetry in hip abductor strength in females increased the risk of acute ankle injury.

Mechanisms of acute ankle syndesmosis ligament injuries in professional male rugby union players: a systematic visual video analysis

BACKGROUND

The mechanisms of acute ankle syndesmosis ligament injuries in professional rugby union are not well understood.

AIM

To describe the mechanisms of acute ankle syndesmosis ligament injuries in male professional rugby union players using systematic visual video analysis.

METHODS

All time-loss acute ankle syndesmosis ligament injuries identified via retrospective analysis of the Leinster Rugby injury surveillance database across the 2013/2014 to 2017/2018 seasons were considered as potentially eligible for inclusion. Three Chartered Physiotherapists (analysts) independently assessed all videos with a final consensus meeting convened to describe the injury mechanisms. One of the analysts developed a qualitative description of each injury mechanism.

RESULTS

Thirteen acute ankle syndesmosis injuries were included in this study. The most common biomechanical presentation of the injured limb was characterised by hip flexion, knee flexion, knee valgus, ankle dorsiflexion, pronation and external rotation of the foot. Six of the included injuries (46%) were the result of an external load application to the injured limb (ie, direct contact injuries). In the other seven instances (54%), the injury was the result of a collapse of the injured player's body mass over the injured ankle joint, while tackling or being tackled, without direct contact to the injured limb (ie, indirect contact injuries).

CONCLUSION

Injuries incurred while tackling were exclusively the result of suboptimal tackle mechanics. A majority of injuries incurred while being tackled involved a posterior tackle, which often resulted in a posterior collapse of the injured player's centre of mass over a fixed externally rotated foot.

Epidemiology of High Ankle Sprains: A Systematic Review

Syndesmotic sprains or high ankle sprains are reported to be associated with increasing morbidity and time loss. The aim of this study was to critically appraise literature on epidemiology of syndesmotic sprains through systematic review of published literatures. A systematic review was conducted online for literature published in English using PubMed and Google Scholar, as per PRISMA guidelines up to April 30, 2019. Predefined eligibility criteria were applied, and the data thus compiled were analyzed. A total of 26 studies were found to be eligible, of which three-fourths involved sporting population. Considerable inconsistency in assessment procedure reporting, injury and injury severity definition with variable unit measures used to describe incidence or injury rate was observed. Meta-analysis and intra- and intersports comparison could not be performed owing to the study heterogeneity and methodological variability. There is a need for standardization in future research, specifically with regard to injury assessment and reporting, demanding heightened awareness and improved diagnostic modalities, as injury epidemiology is integral to the overall injury-prevention conundrum.Levels of Evidence: Systematic review, Level III.

Ankle osteoarthritis and its association with severe ankle injuries, ankle surgeries and health-related quality of life in recently retired professional male football and rugby players: a cross-sectional observational study

OBJECTIVES

To determine (1) the prevalence of ankle osteoarthritis (OA) among former professional football and rugby players, (2) assess the association between ankle injuries or ankle surgeries with ankle OA, and (3) compare the mental and physical quality of life (QoL) between former professional football and rugby players with and without OA.

METHODS

We conducted a questionnaire-based observational study with a cross-sectional design. Former professional football and rugby players were recruited by the Football Players Worldwide and the International Rugby Players. Information concerning ankle OA, sustained ankle injuries and ankle surgeries was gathered (medical record or most recent medical professional). Health-related QoL was assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) physical and mental health scores.

RESULTS

Overall, 553 former professional football (n=401) and rugby (n=152) players were enrolled in the study (response rate of 56%). Ankle OA prevalence among former professional football and rugby players was 9.2% and 4.6%, respectively. Football players were more likely to suffer from ankle OA following every ankle injury and/or surgery. Football and rugby players with ankle OA had similar PROMIS physical and mental health scores to the norm for the general population.

CONCLUSION

Former professional football and rugby players had higher ankle OA prevalence than the general population (3.4%). Football players are more likely to suffer from ankle OA following every ankle injury and/or surgery. No clinically relevant difference was seen for physical or mental health-related QoL among football and rugby players. Preventive measures for ankle injuries are recommended.

Lay of the land: narrative synthesis of tackle research in rugby union and rugby sevens

Objectives

The purpose of this review was to synthesise both injury prevention and performance tackle-related research to provide rugby stakeholders with information on tackle injury epidemiology, including tackle injury risk factors and performance determinants, and to discuss potential preventative measures.

Design

Systematic review and narrative synthesis.

Data sources

PubMed, Scopus and Web of Science.

Eligibility criteria

Limited to peer-reviewed English-only publications between January 1995 and October 2018.

Results

A total of 317 studies were identified, with 177 in rugby union and 13 were in rugby sevens. The tackle accounted for more than 50% of all injuries in rugby union and rugby sevens, both at the professional level and at the lower levels, with the rate of tackle injuries higher at the professional level (mean 32/1000 player-hours) compared with the lower levels (mean 17/1000 player-hours). A player’s tackle actions and technical ability were identified as major risk factors for injury and a key determinant of performance.

Summary/conclusion

Evidence-based education, progressive tackle technique training with a high potential to transfer and law changes have been proposed as key modifiers of player tackle actions and technical ability. Conceivably, all three modifiers working in unison (as opposed to separately) will have a higher potential at reducing tackle injury risk while enhancing performance. With the guidance of tackle injury and performance studies, as well as stakeholder engagement, experiential and explorative tackle research has the potential to inspire innovative injury prevention and performance strategies.

Pain Level, Range of Motion, and Foot Volume Do Not Differ in Recurrent and First-Time Ankle Sprains

Objective. This study aims to describe the clinical features in terms of pain perception, ankle range of motion, and foot volume in participants with recurrent ankle sprains compared with first-time sprains. Methods. Individuals with grade I and II ankle sprains were referred to physiotherapy care for further rehabilitation by their general practitioner. Primary outcome measures were range of movement, pain, and foot volume. Recurrences were described according to engagement in sport. Results. A total of 115 participants were recruited (age = 22.2 ± 6.9 years; female, 84). Neither pain level (P = .822), nor range of motion (dorsiflexion P = .452; plantar flexion P = .436; inversion P = .383; eversion P = .657), nor foot volume (P = .654) were significantly different between the groups: individuals with first-time sprain or with recurrences. Conclusion. Pain and high existence of other lower-limb injuries were reported disregarding the presence of a recurrence. Clinically, it is difficult to differentiate recurrent sprain from a first-time ankle sprain by means of foot volume, range of movement, or pain intensity.

Ankle Sprain Has Higher Occurrence During the Latter Parts of Matches: Systematic Review With Meta-Analysis

Context: Ankle sprains are common injuries in sports, but it is unclear whether they are more likely to occur in a specific period of a sporting game. Objective: To systematically review the literature investigating when in a match ankle sprains most likely occurred. Evidence Acquisition: The databases CINAHL, EMBASE, MEDLINE, and SPORTDiscus were searched up to August 2016, with no restriction of date or language. The search targeted studies that presented data on the time of occurrence of ankle sprains during sports matches. Data from included studies were analyzed as a percentage of ankle sprain occurrence by halftime and by quarters. Meta-analyses were run using a random effects model. The quality assessment tool for quantitative studies was used to assess the article's quality. Evidence Synthesis: The searches identified 1142 studies, and 8 were included in this review. A total of 500 ankle sprains were reported during follow-up time, which ranged from 1 to 15 years, in 5 different sports (soccer, rugby, futsal, American football, and Gaelic football). The meta-analyses, including all 8 studies, showed that the proportion of ankle sprains during the first half (0.44; 95% confidence interval [CI], 0.38-0.50) was smaller than the second half (0.56; 95% CI, 0.50-0.62). For the analyses by quarters, the proportion of ankle sprains in the first quarter (0.14; 95% CI, 0.09-0.19) was considerably smaller than the second (0.28; 95% CI, 0.24-0.32), third (0.25; 95% CI, 0.17-0.34), and fourth (0.29; 95% CI, 0.22-0.36) quarters. Conclusion: The results of this review indicate that ankle sprains are more likely to occur later in the game during the second half or during the latter minutes of the first half.

Chronic musculoskeletal ankle disorders in Sri Lanka

BACKGROUND

Musculoskeletal disorders of the lower extremities are commonly affected by chronicity and disability. One of the most commonly affected areas is the ankle. Epidemiological information is limited for chronic musculoskeletal ankle disorders in the general community, particularly in the developing world. This study aimed to determine the prevalence and impact of chronic musculoskeletal ankle disorders in the Sri Lankan community.

METHODS

A cross-sectional stratified random sample of people (n = 1000) aged 18 to 85 years in Sri Lanka was undertaken by questionnaire in the general community setting. Of those questionnaires, 827 participants provided data. Point prevalence for no history of ankle injury or ankle disorders, history of ankle injuries without chronic ankle disorders, and chronic ankle disorders were obtained. Point prevalence of chronic musculoskeletal disorders and causes for chronicity was evaluated.

RESULTS

There were 448 (54.2%) participants with no ankle disorders, 164 (19.8%) with a history of ankle injury but no chronic disorders, and 215 (26.0%) with chronic ankle disorders. The major component of chronic ankle disorders was musculoskeletal disorders (n = 113, 13.7% of the total sample), most of which were due to ankle injury (n = 80, 9.7% of the total). Sprains were responsible for 17.7% of the total ankle injuries. Arthritis was the other main cause for chronicity of ankle disorders with 4% of total participants (n = 33).

CONCLUSIONS

Almost 14% of the Sri Lankan community was affected by chronic musculoskeletal ankle disorders. The majority were due to a previous ankle injury, and arthritis. Most people had to limit or change their physical activity because of the chronic ankle disorder. A very low utility of physiotherapy services was observed.

Training volume and soft tissue injury in professional and non-professional rugby union players: a systematic review

AIM

To investigate the relationship between training volume and soft tissue injury incidence, and characterise soft tissue injury in rugby union players.

DESIGN

A systematic search of electronic databases was performed. The search strategy combined terms covering: training volume and injury, and rugby union, and players of all levels.

DATA SOURCES

Medline, SPORTDiscus, Web of Science, Embase, PubMed.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies were included if they reported: male rugby union players, a clear definition of a rugby union injury, the amount of training volume undertaken by participants, and epidemiological data for soft-tissue injuries including the number or incidence.

RESULTS

15 studies were eligible for inclusion. Overall match and training injury incidence ranged from 3.3 to 218.0 injuries/1000 player match hours and 0.1-6.1 injuries/1000 player training hours, respectively. Muscle and tendon as well as joint (non-bone) and ligament injuries were the most frequently occurring injuries. The lower limb was the most prevalent injury location. Injury incidence was higher in professional rugby union players than non-professional players. Contact events were responsible for the greatest injury incidence. For non-contact mechanisms, running was responsible for the highest injury incidence. Inconsistent injury definitions hindered reliable comparison of injury data. The lack of reporting training volumes in hours per player per week limited the ability to investigate associations between training volume and injury incidence.

CONCLUSIONS

A higher level of play may result in higher match injury incidence. Muscle and tendon injuries were the most common type of soft tissue injury, while the lower limb was the most common location of injury in rugby union players, and running was responsible for the highest injury incidence during non-contact events.

The Impact and Functional Outcomes of Achilles Tendon Pathology in National Basketball Association Players

Achilles tendon rupture within professional athletes has been shown to lead to devastating consequences regarding return to athletic performance. Not only can this devastating injury affect performance for the remainder of player's career, it frequently becomes a career-ending event. Considering these significant risks associated with complete rupture, the purpose of this study was to evaluate NBA players with a spectrum of reported Achilles tendon pathology, from tendinopathy (insertional and non-insertional) to complete rupture. Between the 1988-1989 and 2010-2011 NBA seasons, we identified 43 cases of Achilles tendon pathology treated non-operatively. A control group was matched for the players able to return to play with the following parameters: age, position played, number of seasons played in the league, and similarly rated career performance statistics. Considering the medical staff, trainers and facilities available to a professional athlete, a "weekend warrior" should be counseled that even in optimal conditions, 14% of NBA players were unable to return to function/play after Achilles tendinopathy, and that those who were able to return did so at a decreased level of performance. In conclusion, players with Achilles tendinopathy have a better chance to return if they are younger in age and early in their professional career. Furthermore, the association between Achilles pathology and decline in player performance is an important message to convey to coaching staff and team management to allow properly informed decisions when these conditions arise.

What does normal tendon structure look like? New insights into tissue characterization in the Achilles tendon

Recently, ultrasound tissue characterization (UTC) was introduced as a reliable method for quantification of tendon structure. Despite increasing publications on the use of UTC, it is striking that there is a lack of normative data in active adolescents. Therefore, the aim of this study was to provide normative values of the Achilles tendon as quantified by UTC. Seventy physiotherapy students (26 male and 44 female students) with no history of Achilles tendon injuries were recruited. The Achilles tendons were scanned with UTC to characterize tendon structure. This study demonstrated that Achilles tendons of active, healthy adolescents contained 54.6% echo type I, 42.8% echo type II, 2.2% echo type III, and 0.3% echo type IV at midportion. The comparison between insertion and midportion of the tendon showed more echo type II at insertion (P < 0.001). Furthermore, female tendons contained significantly more echo type II, in both insertion and midportion compared with male tendons (P = 0.004 and P = 0.003, respectively). The results of this study, with respect to the MDC (minimum detectable change), highlight differences in the UTC echopattern in the normal population (sex and regional location), which are important considerations for future studies.

Frequency and trends in foot and ankle injuries within an English Premier League Football Club using a new impact factor of injury to identify a focus for injury prevention

BACKGROUND

Foot and ankle injuries are common in football. Prevention strategies exist in order to decrease the incidence of such injuries and minimize the number of days that a player is unavailable for selection.

METHODS

Injuries were recorded over a 4-season period while the team was playing in the English Premier League (EPL). We present the epidemiology of foot and ankle injuries within a professional football club and offer a calculation that may be of use in the future to identify areas of injury prevention.

RESULTS

Anterior Talo-Fibular Ligament (ATFL) injuries and fifth metatarsal fractures were of high impact as they were both common and resulted in significant time periods where the player was unavailable.

CONCLUSIONS

This is the first time an EPL club has been prepared to publish data regarding injury. Our findings may be used by others to focus their prevention strategies on the injuries with the highest impact.

Limited ankle dorsiflexion increases the risk for mid-portion Achilles tendinopathy in infantry recruits: a prospective cohort study

Background

Achilles tendinopathy (AT) is a prevalent condition among runners and military personnel. Although ankle dorsiflexion (DF) range of motion (ROM) as measured with the knee bent has not been previously associated with AT, the literature concerning its role is limited. In addition, the role of lower extremity movement pattern in the pathogenesis of AT has not been studied prospectively.

The purpose of this study was to further explore the role of ankle DF ROM as measured with the knee bent and that of lower extremity movement pattern as risk factors for mid-portion AT.

Methods

Seventy healthy male military recruits (mean ± SD age, height and body mass of 19.6 ± 1.0 years, 176.0 ± 10.0 cm, and 71.5 ± 7.4 kg) participated in this study. Ankle DF ROM as measured with the knee bent in weight-bearing (WB) and non-weight-bearing (NWB), as well as lower extremity quality of movement during a lateral step down (LSD) test were measured at baseline. Participants were then followed for a 6-month period of army basic training with recording of the development of AT.

Results

Five participants developed AT during training. Participants that developed AT had a more limited NWB ankle DF ROM (27.4⁰ versus 21.1⁰, p = 0.025). The quality of lower extremity movement did not differ between injured and uninjured participants (p = 0.361).

Conclusions

A more limited ankle DF ROM as measured in NWB with the knee bent increases the risk of developing AT among military recruits taking part in intensive physical training.

Active Achilles tendon kinesitherapy accelerates Achilles tendon repair by promoting neurite regeneration

Active Achilles tendon kinesitherapy facilitates the functional recovery of a ruptured Achilles tendon. However, protein expression during the healing process remains a controversial issue. New Zealand rabbits, aged 14 weeks, underwent tenotomy followed immediately by Achilles tendon microsurgery to repair the Achilles tendon rupture. The tendon was then immobilized or subjected to postoperative early motion treatment (kinesitherapy). Mass spectrography results showed that after 14 days of motion treatment, 18 protein spots were differentially expressed, among which, 12 were up-regulated, consisting of gelsolin isoform b and neurite growth-related protein collapsing response mediator protein 2. Western blot analysis showed that gelsolin isoform b was up-regulated at days 7–21 of motion treatment. These findings suggest that active Achilles tendon kinesitherapy promotes the neurite regeneration of a ruptured Achilles tendon and gelsolin isoform b can be used as a biomarker for Achilles tendon healing after kinesitherapy.

The incidence and prevalence of ankle sprain injury: a systematic review and meta-analysis of prospective epidemiological studies

BACKGROUND

Ankle sprain is one of the most common musculoskeletal injuries, yet a contemporary review and meta-analysis of prospective epidemiological studies investigating ankle sprain does not exist.

OBJECTIVE

Our aim is to provide an up-to-date account of the incidence rate and prevalence period of ankle sprain injury unlimited by timeframe or context activity.

METHODS

We conducted a systematic review and meta-analyses of English articles using relevant computerised databases. Search terms included Medical Search Headings for the ankle joint, injury and epidemiology. The following inclusion criteria were used: the study must report epidemiology findings of injuries sustained in an observed sample; the study must report ankle sprain injury with either incidence rate or prevalence period among the surveyed sample, or provide sufficient data from which these figures could be calculated; the study design must be prospective. Independent extraction of articles was performed by two authors using pre-determined data fields.

RESULTS

One-hundred and eighty-one prospective epidemiology studies from 144 separate papers were included. The average rating of all the included studies was 6.67/11, based on an adapted version of the STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) guidelines for rating observational studies. 116 studies were considered high quality and 65 were considered low quality. The main findings of the meta-analysis demonstrated a higher incidence of ankle sprain in females compared with males (13.6 vs 6.94 per 1,000 exposures), in children compared with adolescents (2.85 vs 1.94 per 1,000 exposures) and adolescents compared with adults (1.94 vs 0.72 per 1,000 exposures). The sport category with the highest incidence of ankle sprain was indoor/court sports, with a cumulative incidence rate of 7 per 1,000 exposures or 1.37 per 1,000 athlete exposures and 4.9 per 1,000 h. Low-quality studies tended to underestimate the incidence of ankle sprain when compared with high-quality studies (0.54 vs 11.55 per 1,000 exposures). Ankle sprain prevalence period estimates were similar across sub-groups. Lateral ankle sprain was the most commonly observed type of ankle sprain.

CONCLUSIONS

Females were at a higher risk of sustaining an ankle sprain compared with males and children compared with adolescents and adults, with indoor and court sports the highest risk activity. Studies at a greater risk of bias were more likely to underestimate the risk of ankle sprain. Participants were at a significantly higher risk of sustaining a lateral ankle sprain compared with syndesmotic and medial ankle sprains.

Developing a framework for ankle function: a delphi study

CONTEXT

Addressing clinical outcomes is paramount to providing effective health care, yet there is no consensus regarding the appropriate outcomes to address after ankle injuries. Compounding the problem is the repetitive nature of lateral ankle sprains, referred to as functional (FAI) or chronic (CAI) ankle instability. Although they are commonly used terms in practice and research, FAI and CAI are inconsistently defined and assessed.

OBJECTIVE

To establish definitions of a healthy/normal/noninjured ankle, FAI, and CAI, as well as their characteristics and assessment techniques.

DESIGN

Delphi study.

SETTING

Telephone interviews and electronic surveys.

PATIENTS OR OTHER PARTICIPANTS

Sixteen experts representing the fields of ankle function and treatment, ankle research, and outcomes assessment and research were selected as panelists.

DATA COLLECTION AND ANALYSIS

A telephone interview produced feedback regarding the definition of, functional characteristics of, and assessment techniques for a healthy/normal/noninjured ankle, an unhealthy/acutely injured ankle, and FAI/CAI. Those data were compiled, reduced, and returned through electronic surveys and were either included by reaching consensus (80% agreement) or excluded.

RESULTS

The definitions of a healthy/normal/noninjured ankle and FAI reached consensus. Experts did not agree on a definition of CAI. Eleven functional characteristics of a healthy/normal/noninjured ankle, 32 functional characteristics of an unhealthy/acutely injured ankle, and 13 characteristics of FAI were agreed upon.

CONCLUSIONS

Although a consensus was reached regarding the definitions and functional characteristics of a healthy/normal/noninjured ankle and FAI, the experts could only agree on 1 characteristic to include in the FAI definition. Several experts did, however, provide additional comments that reinforced the differences in the interpretation of those concepts. Although the experts could not agree on the definition of CAI, its characteristics, or the preferred use of the terms FAI and CAI, our findings provide progress toward establishing consistency in those concepts.

Examining the Relationship Between Pathologies of the Peroneal, Achilles, and Posterior Tibial Tendons: An MRI Review in an Asymptomatic Lateral Ankle Population

The hindfoot and ankle are dynamic structures to which the interplay of tendinous pathologies is scarcely understood. Five hundred consecutive ankle magnetic resonance imaging examinations, obtained between December 27, 2011 and April 9, 2013, were reviewed. Patients without a history of hindfoot or ankle trauma or lateral ankle pain were included. The 108 MRIs that met the inclusion and exclusion criteria were then re-evaluated by 2 musculoskeletal radiologists. Of these, 55.56% demonstrated pathology of the Achilles tendon (AT), 44.44% demonstrated pathology of the posterior tibial tendon (PTT), 35.19% demonstrated pathology of the peroneus brevis (PB), and 37.96% demonstrated pathology of the peroneus longus (PL). In our asymptomatic patient population, 16 (14.81%) patients demonstrated concomitant pathology of the AT, PTT, and peroneal tendons. There were positive, moderate correlations between graded pathology of the AT and the PTT, r_s(106) = 0.32, P = .001; the AT and PB, r_s(106) = 0.38, P = 0.001; and the AT and PL, r_s(106) = 0.46, P = .001. However, there were no statistically significant correlations between pathology of the PTT and PB, r_s(106) = 0.17, P = .08, or the PTT and PL, r_s(106) = 0.14, P = .15. These findings suggest an intimate relationship between the AT, PTT, and the peroneal tendons. These individual anatomic structures may have underappreciated functional relationships that could lead to future investigations.

LEVEL OF CLINICAL EVIDENCE

Level IV.

Chronic ankle instability in sporting populations

BACKGROUND

Chronic ankle instability (CAI) is a term used to identify certain insufficiencies of the ankle joint complex following an acute ankle injury. Acute ankle injuries are often associated with sporting mishaps; however, this review was the first to identify the aspects of CAI (perceived instability, mechanical instability and recurrent sprain), and persisting symptoms following an ankle sprain, that have been reported within sporting cohorts.

OBJECTIVE

To determine the presence of common aspects of CAI within individual sports.

METHODS

A systematic search of the MEDLINE, Web of Science, CINAHL, SPORTDiscus and AMED databases up until 1 October, 2013 produced 88 studies appropriate for review. A calculated weighted percentage of the outcome data allowed the comparison of figures across a range of sports.

RESULTS

Soccer, basketball and volleyball were the most represented sports and recurrent ankle injury/sprain was the most reported aspect of CAI. Soccer had the highest percentage of participants with recurrent sprain (61%) and mechanical instability (38%), whilst track and field had the highest percentage of participants with perceived instability (41%). Gymnasts had the highest percentage of ankles with persisting symptoms following an initial ankle sprain.

CONCLUSION

This review was the first to assess aspects of CAI within sporting cohorts and has identified limitations to the research reporting these data. The problem of CAI across a range of sports remains unclear and thus advocates the need for further controlled research in the area to ascertain the true extent of CAI within sporting populations.

The epidemiology, morbidity and outcome of fractures in rugby union from a standard population

BACKGROUND

Rugby union is the second commonest cause of sporting fracture in the UK, yet little is known about patient outcomes following such fractures.

OBJECTIVE

To describe the epidemiology of fractures in rugby union, their morbidity and the likelihood of return to rugby post-injury in a known UK population at all skill levels.

METHODS

All rugby union fractures sustained during 2007-2008 in the Edinburgh, Mid and East Lothian populations were prospectively recorded, when patients attended the only adult orthopaedic service in Lothian. The diagnosis was confirmed by an orthopaedic surgeon. Patients living outside the region were excluded from the study. Patients were contacted by telephone in February 2012 to ascertain their progress in return to rugby.

RESULTS

A total of 145 fractures were recorded over the study period in 143 patients. The annual incidence of rugby-related fractures was 0.28/1000 of the general population and 29.86/1000 of the adult registered rugby playing population. 120 fractures were of the upper limb and 25 were of the lower limb. 117 fractures (81%) in 115 patients (80%) were followed up at a mean interval of 50 months (range 44-56 months). 87% of the cohort returned to rugby post-injury (87% of upper limb fractures and 86% of lower limb fractures), with 85% returning to rugby at the same level or higher. Of those who returned, 39% did so by 1 month post-injury, 77% by 3 months post-injury and 91% by 6 months post-injury. For those who returned following upper limb fractures, 48% did so by 1 month post-injury, 86% by 3 months post-injury and 94% by 6 months post-injury. In patients who returned following lower limb fractures, 0% did so by 1 month post-injury, 42% by 3 months post-injury and 79% by 6 months post-injury. From the whole cohort, 32% had ongoing fracture related problems, yet only 9% had impaired rugby ability secondary to these problems.

CONCLUSIONS

Most patients sustaining a fracture playing rugby union will return to rugby at a similar level. While one third of them will have persisting symptoms 4 years post-injury, for the majority this will not impair their rugby ability.

Development and validation of the Sports Athlete Foot and Ankle Score: an instrument for sports-related ankle injuries

BACKGROUND

Many existing scoring systems assess ankle function, but there is no evidence that any of them has been validated in a group of patients with a higher demand on their ankle function. Problems include ceiling effects, not being able to detect change or they do not contain a sports-subscale. The aim of this study was to create a validated self-administered scoring system for ankle injuries in the higher performing athlete.

METHODS

First, 26 patients were interviewed to solicit opinions needed to create the final score, which is modified from the Foot and Ankle Outcome Score (FAOS). Second, SAFAS was validated in a group of 25 athletes with and 14 athletes without ankle injury. It is a self-administered region specific sports foot and ankle score that contains four subscales assessing the levels of symptoms, pain, daily living and sports.

RESULTS

The Spearman correlation coefficients between SAFAS and the Foot and Ankle Ability Measure (FAAM) ranged from 0.78 to 0.88. Content validity is established by key informant interviews, expert opinions and a high satisfaction rate of 75%. Cronbach's alpha indicated good internal consistency of each subscale ranging from 0.77 to 0.92.

CONCLUSION

SAFAS has shown good evidence for being a valid instrudent for assessing sports-related ankle injuries in high-performing athletes.

Performance outcomes after repair of complete achilles tendon ruptures in national basketball association players

BACKGROUND

A complete rupture of the Achilles tendon is a devastating injury. Variables affecting return to competition and performance changes for National Basketball Association (NBA) players are not readily evident.

HYPOTHESIS

Players in the NBA who ruptured their Achilles tendons and who underwent surgical repair would have more experience in the league, and the performance of those who were able to return to competition would be decreased when compared with their performance before injury and with their control-matched peers.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data for 18 basketball players with Achilles tendon repair over a 23-year period (1988-2011) were obtained from injury reports, press releases, and player profiles. Variables included age, body mass index (BMI), player position, and number of years playing in the league. Individual season statistics were obtained, and the NBA player efficiency rating (PER) was calculated for 2 seasons before and after injury. Controls were matched by playing position, number of seasons played, and performance statistics. Univariate and multivariate analyses were performed to assess the effect of each factor.

RESULTS

At the time of injury, the average age was 29.7 years, average BMI was 25.6, and average playing experience was 7.6 years. Seven players never returned to play an NBA game, whereas 11 players returned to play 1 season, with 8 of those players returning for ≥2 seasons. Players who returned missed an average of 55.9 games. The PER was reduced by 4.57 (P = .003) in the first season and by 4.38 (P = .010) in the second season. When compared with controls, players demonstrated a significant decline in the PER the first season (P = .038) and second season (P = .081) after their return.

CONCLUSION

The NBA players who returned to play after repair of complete Achilles tendon ruptures showed a significant decrease in playing time and performance. Thirty-nine percent of players never returned to play.

Recurrence of Achilles tendon injuries in elite male football players is more common after early return to play: an 11-year follow-up of the UEFA Champions League injury study

BACKGROUND

There is limited information about Achilles tendon disorders in professional football.

AIMS

To investigate the incidence, injury circumstances, lay-off times and reinjury rates of Achilles tendon disorders in male professional football.

METHODS

A total of 27 clubs from 10 countries and 1743 players have been followed prospectively during 11 seasons between 2001 and 2012. The team medical staff recorded individual player exposure and time-loss injuries.

RESULTS

A total of 203 (2.5% of all injuries) Achilles tendon disorders were registered. A majority (96%) of the disorders were tendinopathies, and nine were partial or total ruptures. A higher injury rate was found during the preseason compared with the competitive season, 0.25 vs 0.18/1000 h (rate ratio (RR) 1.4, 95% CI 1.1 to 2.0; p=0.027). The mean lay-off time for Achilles tendinopathies was 23±37 (median=10, Q1=4 and Q3=24) days, while a rupture of the Achilles tendon, on average, caused 161±65 (median=169, Q1=110 and Q3=189) days of absence. Players with Achilles tendon disorders were significantly older than the rest of the cohort, with a mean age of 27.2±4 years vs 25.6±4.6 years (p<0.001). 27% of all Achilles tendinopathies were reinjuries. A higher reinjury risk was found after short recovery periods (31%) compared with longer recovery periods (13%) (RR 2.4, 95% CI 2.1 to 2.8; p<0.001).

CONCLUSIONS

Achilles tendon disorders account for 3.8% of the total lay-off time and are more common in older players. Recurrence is common after Achilles tendinopathies and the reinjury risk is higher after short recovery periods.

Epidemiology of ankle and foot overuse injuries in sports: A systematic review

Studies regarding ankle and foot overuse injuries are quite diverse in research methodology, data reporting, and outcomes. The aims of this systematic review were to analyze the methodology of published studies regarding ankle and foot overuse injuries in different sports disciplines and to summarize epidemiological data of ankle and foot overuse injuries. Four electronic databases, PubMed (MEDLINE), EMBASE, CINAHL, and SPORTDiscus(®) were systematically searched up to June 2011. A total of 89 articles on 23 sports disciplines were included in this review. Soccer, running, and gymnastics were the most frequently studied sports. Achilles tendinopathy, plantar fasciitis, and stress fracture were the most frequently studied injuries. Study design and reporting methods were heterogeneous. Most studies suffered from a weak methodology and poor reporting. The most common weaknesses were lack of a clear case definition, describing assessment procedures and reporting sample characteristics. Due to methodological heterogeneity of studies, inter-sports and intra-sports comparisons and meta-analysis were not possible. Methodology of most studies on incidence and prevalence of ankle and foot overuse injuries is insufficient. Based on the results, we recommend authors to clearly define cases, describe assessment procedures and report sample characteristics adequately.

Analysis of hereditary and medical risk factors in Achilles tendinopathy and Achilles tendon ruptures: a matched pair analysis

OBJECTIVE

In Achilles tendon injuries, it is suggested that a pathological continuum might be evident from the healthy Achilles tendon to Achilles tendinopathy to Achilles tendon rupture. As such, risk factors for both tendinopathy and rupture should be the same.

HYPOTHESIS

Hereditary and medical risk factors for Achilles tendinopathy and Achilles tendon rupture are the same to a similar extent in a matched pair analysis.

DESIGN

Matched pair study; level of evidence: 3.

SETTING

Recreational sportsmen as well as athletes on national level.

PATIENTS

566 questionnaires were analysed. 310 subjects were allocated to 3 groups (A, B, C) after matching the pairs for age, weight, height and gender: (A) healthy Achilles tendons (n = 89, age 39 ± 11 years, BMI 25.1 ± 3.9, females 36%), (B) chronic Achilles tendinopathy (n = 161, age 41 ± 11 years, BMI 24.4 ± 3.7, females 34%), (C) acute Achilles tendon rupture (n = 60, age 40 ± 9 years, BMI 25.2 ± 3.2, females 27%).

RESULTS

We found a positive family history of Achilles tendinopathy as a risk factor for Achilles tendinopathy (OR: 4.8, 95% CI: 1.1-21.4; p = 0.023), but not for Achilles tendon rupture (OR: 4.0, 95% CI 0.7-21.1, p = 0.118). Smoking and cardiac diseases had a lower incidence in Achilles tendinopathy than in healthy subjects (both p = 0.001), while cardiovascular medication did not change the risk profile.

CONCLUSION

Identifying risk factors associated with Achilles tendon disorders has a high clinical relevance regarding the development and implementation of prevention strategies and programs. This cross-sectional study identified a positive family history as a significant solitary risk factor for Achilles tendinopathy, increasing the risk fivefold. However, in this matched pair analysis excluding age, weight, height and gender as risk factors no further factor necessarily increases the risk for either Achilles tendinopathy or Achilles tendon rupture.

Lateral and syndesmotic ankle sprain injuries: a narrative literature review

OBJECTIVE

The purpose of this article is to review the literature that discusses normal anatomy and biomechanics of the foot and ankle, mechanisms that may result in a lateral ankle sprain or syndesmotic sprain, and assessment and diagnostic procedures, and to present a treatment algorithm based on normal ligament healing principles.

METHODS

Literature was searched for years 2000 to 2010 in PubMed and CINAHL. Key search terms were ankle sprain$, ankle injury and ankle injuries, inversion injury, proprioception, rehabilitation, physical therapy, anterior talofibular ligament, syndesmosis, syndesmotic injury, and ligament healing.

DISCUSSION

Most ankle sprains respond favorably to nonsurgical treatment, such as those offered by physical therapists, doctors of chiropractic, and rehabilitation specialists. A comprehensive history and examination aid in diagnosing the severity and type of ankle sprain. Based on the diagnosis and an understanding of ligament healing properties, a progressive treatment regimen can be developed. During the acute inflammatory phase, the goal of care is to reduce inflammation and pain and to protect the ligament from further injury. During the reparative and remodeling phase, the goal is to progress the rehabilitation appropriately to facilitate healing and restore the mechanical strength and proprioception. Radiographic imaging techniques may need to be used to rule out fractures, complete ligament tears, or instability of the ankle mortise. A period of immobilization and ambulating with crutches in a nonweightbearing gait may be necessary to allow for proper ligament healing before commencing a more active treatment approach. Surgery should be considered in the case of grade 3 syndesmotic sprain injuries or those ankle sprains that are recalcitrant to conservative care.

CONCLUSION

An accurate diagnosis and prompt treatment can minimize an athlete's time lost from sport and prevent future reinjury. Most ankle sprains can be successfully managed using a nonsurgical approach.

The epidemiology of foot injuries in professional rugby union players

BACKGROUND

Foot injuries represent a small but important proportion of injuries to professional rugby union players. There are no detailed epidemiological studies regarding these injuries. The aim of this study was to describe the epidemiology of foot injuries sustained by a cohort of professional rugby union players and identify areas that may be targeted for injury prevention in the future.

METHODS

Medical personnel prospectively recorded injuries in professional Premiership rugby union players in England over four seasons. Injuries to the foot were identified and the time away from training and playing was reported.

RESULTS

A total of 147 foot injuries were sustained resulting in 3542 days of absence in total. Acute events accounted for 73% of all foot injuries, with chronic, mostly overuse conditions, accounting for 25% (undiagnosed 2%). Chronic conditions led to proportionately more time away from training and playing (p=<0.001). Specifically, stress fractures in the foot accounted for 8% of the total foot injuries but 22% of the absence. Navicular stress fractures had the longest recovery time with the mean return to training and match play of 188 days.

CONCLUSION

In collision sports such as rugby, some injuries may be inevitable but clinicians should always be seeking ways to minimise their occurrence and impact. This study revealed a high proportion of morbidity associated with chronic and overuse foot injuries in these professional athletes. With greater attention paid to risk factors, some of these injuries, and importantly, recurrent injuries may be avoided.