Megan Blount, DO¹; Dylan Bui, OMS 2026²; Jennifer FitzPatrick, MD³; Christopher LaFontano, DO^2
1UC Davis Health
²Rocky Vista University COM – Utah Campus
³Parkview Orthopedics

Abstract

Case
Injury is an unfortunate consequence of playing American football, with injury rates in football being the highest across all sports at the high school and collegiate levels. Ankle injuries are among the most common, ranging from sprains to fractures. This paper examines three separate distal fibula fractures with syndesmotic injuries associated with collegiate American football players who experienced non-contact injuries on synthetic turf fields while wearing similar footwear designed for turf surfaces. These injuries were managed with open reduction internal fixation and syndesmotic fixation with suture button(s). 

Conclusion
This recurrent injury pattern prompts a discussion on the health and financial impacts of sport surfaces like synthetic turf as well as footwear-surface interface on lower extremity injury risks and implications for athletes.

Keywords: Syndesmotic Injury, Ankle Fracture, Weber C, Pronation-External Rotation Injury, Non-Contact Injury, Artificial Turf

Introduction
Football has the most injuries across all sports at the high school and collegiate levels (1-2). Orthopedic injuries to the lower extremities dominate the sport, particularly injuries to the knee and ankle (3). 

In recent history, the type of sports surfaces and their impact on both contact and non-contact injuries have become increasingly common. Natural grass releases cleats more readily than synthetic turf, and several studies posit that the differing forces these surfaces exert on an athlete’s body mechanics can contribute to lower extremity injuries (4-7). 

Statement of Informed Consent
Each athlete was informed that de-identified clinical data would be submitted for publication and provided informed consent. 

Case Presentation
Three college athletes suffered right Weber C distal-third oblique fibular shaft fractures with associated syndesmotic injuries while playing football. Athlete A was a 21-year-old male tight end with no prior history of ankle injury or instability who suffered a fracture-dislocation which he self-reduced on the field after performing a cut motion with external rotation while running a route. He was placed in a short leg splint after injury to stabilize the ankle and allow the soft tissue to be amenable for definitive surgery. Athlete A’s fibula fracture was managed with open reduction internal fixation (ORIF) with direct reduction followed by application of a 12-hole 1/3 tubular bridge plate with non-locking screws. A large reduction clamp was placed across the ankle mortise to reduce the ankle syndesmosis, followed by the placement of two Arthrex Tight-Rope™ (Arthrex, Inc, Naples, FL) to anatomically reduce the syndesmosis. Proper placement and reduction were confirmed with intra-operative x-ray and syndesmotic integrity was confirmed with manual external rotation stress under fluoroscopic visualization. Initial injury and immediate post-operative radiographs are shown in Figure 1A. Following closure of his incisions he was placed in a short leg splint. He was made non-weightbearing with crutches for eight weeks post-operatively and instructed to follow up at two weeks post operatively to transition from splint to removable boot. He continued to follow up at one, two and three months post-operatively. At his three month visit he endorsed some swelling but minimal pain but had been working on range of motion and unilateral strengthening exercises. He was able to perform single leg squat and calf raise at this visit. His most recent follow up was at six months post-operatively where he continued to have residual swelling of his right ankle with mild paresthesias to the dorsal aspect of the distal foot with positive Tinel sign on his right peroneal nerve. He had, however, been making progress with strengthening at this time and was scheduled to begin returning to football practice after this visit. 

Athlete B was a 23-year-old male wide receiver with no prior history of ankle injury or instability who suffered a right ankle injury when he landed back on the ground after jumping to catch a pass during a game. His fibula fracture was managed with ORIF with direct reduction followed by application of a 10-hole 1/3 tubular bridge plate with non-locking screws. It was determined intraoperatively through external rotation stress testing that the distal tibiofibular syndesmosis and deltoid ligament were affected and unstable. A periarticular clamp was placed across the ankle mortise to reduce and stabilize the syndesmosis. Anatomic reduction was achieved with two Tight Ropes. Initial injury and immediate post-operative radiographs are shown in Figure 1B. He was placed in a splint and made non-weightbearing on his right lower extremity for eight weeks with instructions to follow up in clinic at two weeks post-operatively for an incision check and transition to removable boot. He then followed up at around the six month post-operative period in the team training room where he was missing five to eight degrees of dorsiflexion and three degrees of plantarflexion with plan to continue range of motion and strengthening exercises. There is no other documentation between the two week and six month follow up visits, however the orthopedic surgeon serves as the team physician and evaluates the athletes outside of the clinic. 

Athlete C was a 23-year-old male wide receiver with no prior history of ankle injury or instability who experienced a right ankle fracture dislocation during a game when an opposing player collided with him on his right side. He was immediately tender to the lateral aspect of his right lower extremity. He was sent to the emergency room where he was splinted and admitted overnight for pain management and observation with surgical fixation the following day. Two 2.7 mm lag screws were used to hold reduction of the butterfly fragment and fracture followed by application of an 8 hole 3.5mm Dynamic Compression Plate with Limited Bone Contact (LC-DCP) construct used as a neutralization plate. Cotton test was performed that didn’t appear to demonstrate instability, however external rotation stress did rotate and widen the syndesmosis. A large reduction clamp was placed across the mortise to reduce the syndesmosis, followed by the placement of a single Tight Rope to achieve anatomic reduction. Proper placement and reduction were confirmed with intra-operative x-ray. Figure 1C depicts Athlete C’s injury and post-operative films. His post-operative plan included non-weightbearing to his right lower extremity for eight weeks, with plan to transition from splint to removable boot at two weeks after surgery. His last follow up in clinic was at six weeks postoperatively where he was still non-weightbearing in a removable boot, only coming out for bathing and ankle range of motion exercises. At this visit, he had thirty degrees of plantarflexion and zero degrees dorsiflexion with mild generalized muscle atrophy over the right foreleg.  

All three athletes were out for the remainder of the football season and have not returned to game participation, however documentation from Athlete A’s six-month post-operative visit indicated his intent to return to practice. 

Discussion

Turf vs Natural Grass
Natural grass releases cleats more readily than synthetic turf, and increased loading of forces on the foot can contribute to lower extremity injuries (4). National Football League (NFL) data determined that play on synthetic turf resulted in a 16% increase in lower extremity injury per play compared to that on natural grass fields (incidence rate ratio: 1.16; 95% CI, 1.10-1.23) and the elevated injury rate was stronger when injuries were restricted to non-contact versus surface contact injuries (4). Major League Soccer (MLS) found that overall ankle injury, as well as Achilles injuries and ankle fractures have a statistically higher incidence on artificial turf sports fields (6). Similar trends have been identified across all sports and levels of competition, where artificial turf had higher incidences of foot and ankle injuries compared to natural grass (5, 7-8). 

Some research has posited that artificial turf and natural grass have similar injury risk, but each surface has the potential for distinct injury patterns (9). Artificial turf was associated with higher incidences of ankle injuries, however ligamentous knee injuries had higher injury incidence on grass fields (9-10). Fuller determined ankle ligament tears were the most common season-ending injury in male athletes practicing on artificial turf (11). However, their follow-up study found in competition there was a small, nonsignificant increase in ankle ligament injuries for men and a reduction in ligamentous injury in women on artificial turf (12). 

Cleat Loading Patterns
Ford et al (2006) found natural grass had higher peak pressures on the medial forefoot and significantly higher relative load on the lateral midfoot, whereas artificial turf exerted stronger lateral forces over the central forefoot and lesser toes, which could result in increased foot inversion and increased risk of acute ankle injuries. Alternatively, Villwock et al (2009) explored the relationship between cleat patterns and rotational stiffness and found turf-style cleats produce the lowest peak torque, however they also found when compared to natural grass, peak torque and rotational stiffness were significantly higher on artificial turf, which poses increased injury risk (14). With the current design of shoes aiming to minimize slippage of a planted foot, this could increase the risk of eversion injuries like the ones suffered by the three aforementioned athletes, which occur at a 31% (p<0.001) higher rate on artificial turf versus natural grass (15-16). 

More recent studies examined the effect of cleat design on load patterns when performing football specific tasks and movements. Taylor et al (17-18) examined shoe design on metatarsal and midfoot loading during resisted pushing tasks. They found standard cleats had higher forces on the medial and lateral midfoot as well as the central and lateral forefoot and lesser toes, but lower forces on the hallux compared to the turf cleat (18). They determined turf design produced higher relative loads in the lateral foot and higher levels of midfoot stiffness compared to the grass cleat design, which could promote higher levels of dorsiflexion at the forefoot and may increase risk of eversion injury (17). 

Alternatively, Silva and colleagues examined cleat-surface interaction in soccer players and found there was no statistically significant cleat-group main effect on forces exerted on peroneal muscles (19). They concluded cleat type didn’t influence potential for ankle sprain on artificial grass, however athletes with ankle instability had delayed muscular adaptation of the peroneus longus and with turf shoes (19). 

Financial Impacts
A less discussed impact of non-contact lower extremity injuries is the potential financial cost to the athlete. In 2023, the National Football Foundation reported that of the over one million high school football players in the United States, just 7.8% will play at the collegiate level, and of those college athletes, 0.41% made an NFL opening week roster in 2022 (20). With the potential for employment and financial security on the line, the impact of what could be a preventable non-contact injury goes beyond the physical and psychological effects of injury. While there is limited data on the financial impact of non-contact injuries resulting in an unstable ankle syndesmosis, much can be inferred by the data regarding other sports-related lower extremity injuries. 

For athletes hoping to jumpstart or maintain their professional career, reducing extremity injuries and optimizing their recovery timeline can impact future contracts. 

Studies show injury incidence in football has steadily increased over time. Data from NFL players from 2009 to 2020 have shown that the incidence of high ankle sprains and syndesmotic injury has increased significantly, with 0.067/10,000 player exposures in 2009 to 2.49/10,000 player exposures during the 2019/2020 NFL season (21). While 90% of players suffering from syndesmotic injuries return to sport, the average recovery period was 11 weeks, a significant portion of an NFL season (21). DeFroda et al found that increased player age had increased risk of failing to return to sport after injury (21). Studies also examined return to sport timelines for syndesmotic injuries, however there is significant variability, as there is subjectivity to a player’s “return” to sport, a wide spectrum of injury severity, and differences in level of play, as some studies explored injuries in recreational athletes while others studied elite athletes (22).  One study similarly found that 90% of NFL athletes with distal fibula fractures returned to play, however they didn’t compare rates between conservative and surgical management (22-23). They found surgery resulted in more days lost to sport compared with conservative management, which may be linked to injury severity (123.8 vs 75.3 days) (23). Mai et al examined the effect of orthopedic procedures on NFL football athlete careers and found athletes with ankle fractures experienced a reduction in their performance at one year after injury, but were able to return to baseline at two to three years post-injury (22, 24). These conclusions infer those with higher functional demand may take longer to return to pre-injury function, if at all, which is further supported by data showing 12% of competitive athletes return to sport after operative ankle fractures, compared to 88% of recreational athletes (22, 25). 

The overwhelming consensus is that most high-level athletes can return to sport, with the amount of time to recovery being dependent on injury severity and if surgery was required (21-26). The question remains, in players that are still developing who may not have contracts with guaranteed money, if they are able to rehabilitate after these injuries and secure a future in a professional league, or will their injury prevent them from becoming the 0.41% who make the cut.

Conclusion
Injury is an inevitability in many sports at all levels of competition. This paper examined three separate football injuries with near identical fracture patterns and syndesmotic instability after noncontact injuries on turf fields. The nature of these injuries warrants discussion about playing surface and footwear-surface interaction on injury risk. Understanding these risk factors could be key to injury prevention and the long-term personal, economic, and psychological consequences on the athlete. Future investigations could explore gait and force pattern analysis to develop safer equipment for athletes. Alternatively, investigation into non-contact syndesmotic injuries with fibula fractures and their implications for return to sport is warranted.

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