Wednesday, June 07, 2006

Will we see him after the break?

Speculation mounts that England will be up to its full squad by the beginning of the competition. Wayne Rooney the Manchester United striker and star England player, has been spotted kicking ball which means it is now a question of watch and wait. Confronted by a spate of similar foot injuries to David Beckham , Danny Murphy , Steven Gerrard , Michael Owen , Gary Neville and Roy Keane it seems perfectly natural to seek a general cause. Some like Tommy Docherty echoes the opinions of some sports injury specialists suggesting the lightweight nature of current boots, designed for precision ball control and traction do not provide adequate protection; whereas other raise an eyebrow at the punishing training and game schedule set for players at the top of their profession. A factor that is hard to discount, in the face of the grueling and congested nature of the domestic season in Britain. Nike were adamant their boots did not contribute to the injury. Details remain confused but it appears Rooney suffered a fracture of his fourth metatarsal on his right foot and not a stress fracture (March Fracture or hairline crack), as was previously reported. The former takes time to heal and would not resolve within six weeks however even when completely rested. Norman Whiteside has cautioned players recovering from a broken metatarsal should not return to play even when they are 95 per cent healed as the fragile bone is likely to refracture and or the player may pick up another injury.
Contrary to the press and their interest in soccer elite stress fractures were first described by Aristotle in 200 BC, and entered medical literature in 1855 when a Prussian military physician called Breithaupt, described what is now known as a "march fracture" (stress fracture of the metatarsals). Metatarsal fractures represent approximately 25 percent of all stress fractures reported and are not limited to elite athletes or military recruits. They are seen in runners of all levels, ballet dancers, gymnasts, those engaged in high-impact aerobics, as well as people with rheumatoid disease, those with metabolic bone disease, and neuropathic conditions. Stress fractures are estimated to comprise up to 16% of all injuries that are related to athletic participation; running is the cause in most of these. Most stress fractures (95%) involve the lower extremities; the metatarsals are most commonly involved. It is more usual for the second and third metatarsal to fracture with the fourth being quite rare. In severe cases more than one middle metatarsal may be involved. There are several factors which contribute to the development of stress fractures and generally these occur as a result of a repetitive stress injury that exceeds the intrinsic ability of the bone to repair itself. Histologists believe bone is more susceptible to injury when there is a delay between osteoblastic and osteoclastic activity and when combined with unusual or prolonged tensional and bending stresses acting across the foot result in micro-fractures appearing as weakness in the small bone. Strong and repetitive stress on bone at the insertion point of muscles, resulting in focal bending stresses beyond the ability of the bone to tolerate will result in full fractures. Approximately 60 percent of people with a stress fracture have had previous occurrences and are a higher risk of a complete fracture (as in the case of Rooney). The second, third and fourth metatarsals are relatively fixed in position within the foot whereas the first and fifth remain moderately mobile. Greatest stress is placed on the middle three metatarsals when longitudinal twisting occurs due to prolonged pronation into propulsion. The first metatarsal can fracture but this is often due to abrupt trauma (traumatic fracture) whereas the fifth metatarsal can fracture relatively easy at its base where the peronei muscle is inserted. This is an avulsion fracture and associated with a lateral ankle strain. In footballers such as Michael Owen, this may have arisen during weightbearing or as likely when a tangerial force caused the ankle to abruptly invert during non weight bearing flight e.g. striking the ball or being hit by another boot. A true Jones fracture will arise when the proximal diametaphyseal junction is broken due to an overpull of the peronei muscles. Despite Owen and Rooney having metatarsal fractures these were likely to be quite different in their causation although overuse may have contributed. New boot designs do everything to improve foot function during the contact sport including protection the foot from injury. The trend within the new generation of boots is to encorporate a shell reinforcement similar to a racing car to support the arch during propulsion (and when the foot contacts the ball mid air). Cleat (or stud) position varies and favours player preference, but composition polyurethanes give wider opportunity to cope with take off and landing forces. Boots are more flexible and lighter in weight and some contain flexible metallic type sheeting within the mid sole which adapts to peak pressures between bone and stud position. These really contain all that is known about material science and biomechanics of the sport. The incidence of fractures of the middle metatarsals in elite soccer players is more than likely due to over training and playing schedules. Further fielding players with less than a 100% recovery supported by cortisone and or local anaesthetic injections are both controversial and reckless disregard for personal safety. Let us hope that does not arise in the FIFA World Cup Germany 2006 .

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