Ankle Injuries in Youth Soccer: Causes and Treatment
Gerry Delahunt is a sports physiotherapist residing in England. He has worked with professional teams throughout his career and is providing his wide range of knowledge to Football.com in order to help youth soccer players, coaches and parents learn more about soccer injuries.
Ankle injuries are common in soccer are and not restricted to the open-age adult game.
Injuries to the ankle can affect players of all ages and abilities, but unlike adults who have sustained an ankle injury, there are some things that we need to be aware of when dealing purely with players of a younger age group.
This doesn’t just apply solely to ankle injuries either, since most of the principles also apply to other joints in the body.
The ankle joint has been the subject of considerable research over the years. Many of the studies have been sport-specific; and with that, identifiable risks have been highlighted according to the demands of any given sport.
It’s probably no surprise to mention that soccer carries one of the highest risks of ankle injury amongst all the contact sports; yet often in soccer the worst of the ankle injuries can easily be sustained without any contact being made with an opponent!
How Do Ankle Injuries in Youth Soccer Usually Happen?
Injuries in sport are normally sustained in one of two ways; either through direct contact with an opponent or team-mate; or through non-contact mechanisms such as twisting or falling. Some of the worst ankle injuries can be sustained in non-contact situations and often there isn’t an opponent or anyone in the immediate vicinity.
The functional anatomy of the ankle involves the talus, or ankle bone, which is a wedge-shaped bone articulating with the lower end of the tibia, or shin bone, and the lower part of the fibula. The tibia is a fully weight-bearing bone while the fibula is the long thin bone that runs down the outside of the leg. The function of the fibula is essentially to provide the origins for the muscles that act on the foot and the lateral (or outside part) of the ankle including the ligamentous structures that support the joint.
Below the talus sits the calcaneus, or heel bone, and the joint formed by the articulation between these two bones is known as the sub-talar joint. This is where the inversion, or ‘turning-in’ movement together with the opposite –eversion - occurs.
All the bones in the ankle complex are bound together by strong ligaments; of which the most frequently injured is the anterior talo-fibular ligament; or ATFL for short. In the adult population, the ATFL has been found to have the lowest tensile strength of all the ankle ligaments and is the weakest in comparison to the others (Pincivero 1993). It is the combination of movements between the ankle and sub-talar joints that leads to ligamentous sprains.
In the immature skeleton, growth plates lie at the ends of the tibia and fibula. These are cartilaginous areas that will adapt as skeletal maturity occurs; eventually turning into solid bone. Growth plates are found at the ends of all the long bones in the body, and are associated with height and physical development. As the body changes in the years leading up to maturity, these soft plates will be replaced with solid bone.
Growth plates don’t have the same strength as the bones they serve and as such are very susceptible to injury. Being weaker than ligaments or tendons means that any force leading to an injury of a soft-tissue nature is also likely to involve the growth plate; and this often results in a fracture. Accordingly, an injury that would present as a sprain in an adult has the potential to result in a more serious growth plate injury in a child or adolescent.
Fousekis (2003) looked at ankle injuries in soccer and found that a high percentage of these (17%) did not involve direct contact with an opponent.
Players who had sustained previous ankle injuries leading to ankle instability were also deemed to be at a higher risk of recurrent ankle injuries in the future. Most of the injuries to the lateral ankle complex involved the ATFL and these usually result from forced inversion movements combined with plantarflexion which leads to tissue damage, bleeding, inflammation, and swelling.
The classic mechanisms of non-contact lateral ankle sprain are catching the foot in a divot while running, or going over on a bumpy field. Due to the forces and angles involved, the ankle then ‘twists’ leading to a tearing of a ligament, or ‘sprain’.
What Exactly Is An Ankle Sprain?
Lateral ankle sprains are often misdiagnosed in the early stages as several associated injuries can complicate matters. Caine (2006) noted that in a series of studies, acute injuries to the growth plates accounted for 30% of adolescent sport injuries; most of which were reported as sprains, and not all of these were seen by a physician.
There’s a tendency to categorize injuries in sport and people often assume that any ankle injury “is only a bad sprain”, and in the case of the adolescent or growing athlete this is a particularly dangerous assumption to make.
There’s an old phrase associated with the word ‘assume’ and of all the throw-away comments I often hear about sports injuries then any involving assumptions are best avoided.
A sprain is the medical term to describe the tearing of a ligament; but you don’t hear anyone saying that “you’ve only torn a ligament!”
In adult players, a ligament tear is relatively straight-forward to address, but with younger athletes the effects of a severe ligamentous sprain on the growth plate can lead to delayed or incomplete recovery, in addition to the potential problems this may have in future life. Examination by a physician will provide appropriate guidance on whether X-rays or further investigation is indicated.
Treatment of Ankle Injuries in Youth Soccer
The early management of ankle injuries often centers on establishing whether a fracture is present and ordinary investigations include plain X-rays requested by a physician.
Provided radiology is used appropriately, X-rays are perfectly acceptable and can be regarded as the first step in a progressive investigative process leading to MRI scanning; which is now the preferred method of investigation for soft-tissue ankle injuries. Injuries to the growth plate may not show on initial X-rays anyway, therefore MRI scanning is often required for accuracy of imaging.
Most routine soft-tissue ankle injuries don’t require X-rays; and people nowadays tend to avoid radiology unless it’s absolutely essential. However, the use of X-rays to determine the presence of bony ankle injury has been thoroughly researched in recent years.
Clinicians adhere to the Ottawa Ankle Rules which provide clear indicators based on trialled research to indicate the likelihood of a fracture being present (Bachmann 2003). Injuries to the joints in adolescent players, though, requires a different investigative protocol to those of adults with ankle sprains due to the potential for the growth plates to be involved.
To illustrate this, Clark and Tanner (2003) studied 195 ankle injuries in children with a mean age of 12.6 years presenting to an Emergency Medical department and concluded that the Ottawa Ankle Rules are not an accurate predictor of fracture in this age group.
The highest rate for growth plate injuries occurs in boys aged 14 years and in girls between the ages of 11 and 12. This is because the female skeleton matures earlier than the male; therefore age for age, more growth plate injuries will be recorded in older boys.
Complications of growth plate injuries include misalignment of the healing tissue and altered growth leading to deformity of the bone in addition to the usual problems of recurring injury and weakness. Additionally, studies by Marsh and Daigneault (2000) highlighted that growth plate injuries can arise from repetitive trauma as opposed to being the result of a single specific accident.
Further Suggestions on How to Handle Ankle Injuries
Shanmugam and Maffulli (2008) concluded that most sports injuries in children and adolescents are limited to mild contusions, sprains and strains. That being the case, immediate management of any soft-tissue injury centers on the standard protocols of protection from further injury followed by rest, with applications of ice, compressions and elevation. In this respect, adolescents are no different from adult players and ankle injuries are managed the same as any other lower limb injury.
The first priority is to limit the damage caused to the tissues and this means coming off the field the moment the injury is sustained in order to protect the ankle from further trauma. It’s also better not to walk off the pitch either if it can be helped since at that stage a fracture hasn’t been excluded, and it goes without saying that trying to ‘run it off’ isn’t to be recommended.
Injured players need to be helped from the field without putting any weight through the joint, either by being brought off on a stretcher or board, and then being seen by a physician or taken to the emergency department of the nearest hospital with the ankle immobilized to prevent further injury.
Acute injuries need to be managed correctly in the early stages not only to aid recovery but also to avoid further aggravating the injury.
When examining the ankle during the acute period, which lasts from the moment the injury is sustained until roughly 48 – 72 hours, it’s important not to disturb the injury. This also applies for the first 5 – 7 days since at that stage the injury is still settling and the last thing that’s needed is for somebody to stick their fingers into damaged tissue and say “does that hurt?” when they know perfectly well that it does!
Healing tissue fibres are often aggravated in this way and the best thing to do is to leave the injury to settle, begin gentle movements without turning the ankle inwards or outwards, and allow the joint to rest in a neutral position with the foot pointing neither up nor down.
However, resting the ankle in slight dorsiflexion, which is the movement involved in bringing the foot and toes upwards, will feel more stable and minimize any tissue disruption.
Letting the foot ‘sag’ only puts an additional stress on the injured tissues and the injury is likely to lake longer to respond if the ligamentous structures aren’t allowed to heal in a natural position. It’s important to avoid the inversion movement in particular during the first couple of weeks if the injury is to the ATFL and / or lateral ankle ligamentous complex to avoid unnecessary elongation of the ligaments.
Ankle ligamentous injuries in general respond well to active rehabilitation instead of immobilization if the damage is confined to the soft-tissue structures. However, if there are associated injuries present such as fractures or injuries to the growth plates, then directed input from a physician or physical therapist is essential and may require a period of immobilization to allow correct recovery to take place undisturbed as opposed to pure self-management.
Usually a period of three to four weeks in a cast or splint is enough time to allow for adequate healing if a non-displaced growth plate fracture has been detected. However, if there is a misalignment is noted either on the X-ray or MRI scans, then surgery may be required to allow correct healing to take place.
So that simple ankle sprain may not be so straight-forward after all.
It’s important when dealing with injuries of this nature to remember that the developing skeleton is doing exactly that – developing.
Accordingly, conditions associated with the developmental growth stages need to be considered when managing adolescent soccer injuries.
Bachmann LM, Kolb E, Koller MT, Steurer J, Reit GT (2003). Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: a systematic review. British Medical Journal.Vol. 326, 22nd February 2003, 417 - 419.
Caine D, Di Fiori J, Maffulli N (2006). Physeal injuries in children’s and youth sports: Reason for concern? British Journal of Sports Medicine. Vol. 40; 749 – 760.
Clark KD, Tanner S (2003). Evaluation of the Ottawa Ankle Rules in children. Paediatric Emergency Care. Vol. 19 (2); 73 – 78.
Fousekis K, Tsepis E, Vagenas G (2012). Intrinsic risks factors of non-contact ankle sprains in soccer: a prospective study on 100 professional players. American Journal of Sports Medicine. Vol. 40 (8); 1842 – 1850.
Heyworth J (2003). Ottawa ankle rules for the injured ankle (editorial). British Medical Journal. Vol. 326; pp 405.
Marsh J, Daigneault J (2000). Ankle injuries in the paediatric population. Current Opinion in Paediatrics. Vol. 12 (1); 52 – 60.
Pincivero at al, 1993; Ankle Injuries.inFootball Traumatology, Current Concepts from Prevention to Treatment. Volpi V (2006), Milan, Springer.
Shanmugam C, Maffulli N (2008). Sports Injuries in Children. Oxford Journals, Medicine & Health, British Medical Bulletin. Vol. 86 (1); 33 -57.