July 17, 2017 Kelly Slater posted on his Instagram this pic1:
After retrieving my jaw from the floor and processing the severity of what had happened to his foot, I couldn’t help but to think.. well.. this season is probably done. Not to be Debby Downer, but he fully broke and displaced his third and fourth metatarsals… on his rear foot. It’s kind of a big deal.
Metatarsals play an important role in gripping, balancing, and assisting the toes with sagittal plane movement. Additionally, some of the metatarsals serve as anchor points for foot and ankle tendons that are critical for surfing. Somehow, I will say, that if there was a silver lining for Kelly Slater’s recent injury, it is that he managed to spare his 1st metatarsal, which is critical for walking, pushing off the ground, and certainly crucial for driving the board down the line (if you don’t believe me, check out his first metatarsal area that shows extra bone growth formation, indicative of repetitive use and possible a pretty cool adaptation for his foot). Also, Slater managed to spare his 5th Metatarsal which is an anchoring point for peroneus brevis a critical muscle for everting ones foot (skipping the fancy talk just think about the motion your back foot goes into as you dig into the tail of your board). Pretty eloquently played Kelly if you have to break your metatarsals!
This isn’t to say however that the 3rd and 4th metatarsals are devoid of importance, function, or more crucially that their recent injury couldn’t be accompanied by other troublesome issues. While this is not an exhaustive list, a few concerns that come to my wandering physical therapist mind include:
–metatarsal dorsalgia : this essentially is a nerve entrapment or irritation often worsened by compression and close boxed shoes… would this mean Kelly would have to wear flip flops indefinitely.. even on the golf course?)
– plantar fasciaitis: (the tissue that attaches from your heel bone/calcaneus to your metatarsals, assists in supporting the foot as a rigid lever arm, as well as absorbs shock, can become irritated, inflamed, and ultimately make walking on flat land or sand very challenging)
– non union/ poor bone formation and/or arthritis: any time you have a broken bone, you run the risk of it not healing together, creating a delay in recovery, and/or healing in a way that promotes poor joint mechanics ultimately leading to stiffness or achi-ness in the affected joints/ bones.
Foot and ankle injuries are very common to competitive surfers.. Just look at the list: Toledo, Wright, Conlogue.. the list goes on. And to prove the point.. remember this article from Surfline just last year (scarily predicting Kelly Slater’s injury to an extent)2?
Several studies conducted at Bond University and the HPC have identified that competitive and professional surfers are more prone to foot and ankle injuries than recreational surfers (3). Additionally, other studies have identified screening tools and predictive factors for foot and ankle injuries in competitive male and female surfers(3-7). Yet, there still is a lack of connect however between research world and real-life or clinical application of some of these land based screening tools as evidenced by the prevalence of foot and ankle injuries within professional surfing just in the last year or two.
At this time, it’s just about impossible to predict how someone could better react or train in the water given the circumstances such as those occurring this past week at J Bay with Kelly. In ‘uni-corn dream world’, I have envisioned a waterproof version of a pressure sensor (such as BodiTrak for golf) embedded into a stomp/tail pad, allowing for real-time recording our foot and ankle’s reactions to unanticipated surf conditions.
This could record or give real-time feedback via waterproof watch or post-session screening that could entail allow for higher performance training. But, barring several (note, on the magnitude of 20) thousand dollars in development for this, (and more rainbows and butterflies), I have come up with some strategies to at least help surfers return to sport, hopefully preventing future injury or other sequelae as outlined above.
You really of course have to take into consideration that literally every foot ankle injury and recovery is different… can respond differently.. and so these are considerations, not hard and fast rules..and certainly just a scratch on the surface of what could be possible…
1) Range of Motion: Not only are we talking about the injured joint itself, but above and below the site of injury too. Form follow function and each part of your foot has an important role of either stability or mobility. So, for example, in Kelly’s case, I’d be pretty interested in making sure his 1st and 5th metatarsal have appropriate mobility, his toes can flex and extend appropriately, and that his ankle joint has good dorsi/plantar flexion. Some ideas for range of motion type exercises in this phase of healing could include:
- towel ‘scrunches’
- using putty for foot/ toe exercises
- picking up marbles with your toes
I’d also be taking a pretty close look at sagittal and transverse plane mobility of the hip knee too.
2) Motor Control and Postural Awareness
You need to think about the brains ‘wiring’ to the foot and ankle, and make adaptations for possible informational inaccuracies. What? Well consider that most of the ligaments in your foot and ankle are home to hundreds if not thousands of ‘proprioceptors’ or sensors that tell us where we are positioned in space. What happens when you stretch or tear a ligament? Well.. these receptors also get stretched and can in turn relay mis-information to our brains. The hack? Well, lots of balance and visual feedback training to re-educate these receptors and your brain. Learning how to achieve a ‘subtalar neutral’ foot posture is one way of doing this, and can prove to be a valuable training tool during this phase of recovery. Many of these types of drills exist, but examples could be:
-single limb/ double limb balance on an Air-Ex pad or BOSU ball, of Dyna-disc
-practice all balance and motor control with eyes open/closed, add head turns/nods
-you could use a biofeedback device such as BodiTrak(R) which is used in the golf world to get better feedback about foot pressure/ posture.
3) Stretching: Consider whats ‘tight’ because it’s living in a constantly lengthened position, and what’s ‘tight’ because its being overused or contracted. Sometimes we need to not only stretch contractile tissue such as muscle or tendon, but other ligamentous structures too. It takes some time (usually at least 20 seconds) for collagen to make a conformational change during a stretch, so plan accordingly when working through this. Things to consider here could include:
-gastroc/ soleus complex
While this seems like a no-brainer, it is a good idea to rebuild muscle strength in muscles above the foot and ankle as well as the foot and ankle itself. Even if you have a weight bearing precaution at the foot, open chain, non-weight bearing type exercises for the trunk, hip, and knee are important. Additionally, anything that will promote circulation and metabolism of inflammatory byproducts will usually speed recovery. Strengthening can happen in a functional way, such as practicing walking barefoot in sand, on sloped surfaces, can be concentric or eccentric in nature, or could use various tools such as:
-gym ball (think bridges or core stability)
5) Agility and Dynamic Stability:
These types of exercises improve shock absorption, further your base strength and may include activities such as plyometrics, eccentric loading, skipping, running. You may find the following equipment to be helpful during this phase of rehabilitation:
The above steps are somewhat sequential in that it’s pretty hard to load and strengthen a foot (steps 4 and 5), on an ankle that doesn’t have appropriate balance and awareness of spatial position (step 2). That said, I would never recommend rehabbing without professional guidance after a severe foot and ankle injury either. These steps outlined above could be used more as a preventive tool or guideline.
Ultimately, what happened to Kelly’s foot this week was a pretty severe injury, and I wish him the very best with his injury recovery and healing process. That said, I think we’ve seen A LOT of this type of foot and ankle injuries within the competitive aspect of surfing, and we really need to push forwards as this sport grows to unite some of the outstanding research coming from educational and private universities with real-life training tools and technology. Ultimately as we educate surfers, promote better technology for understanding and relating these types of injuries, we can put into effective better preventative training programs, and hopefully limit some of these potentially career-ending type of injuries. Surfing will only continue to evolve with more ariel maneuvers, the advent of wave pools, and ever changing board technology. We must grow our supporting structures for our athletes (as soccer, running, basketball, and golf have) if we hope to progress the industry.
- “Slater, Kelly. ‘#ThatsGonnaLeaveAMark.’ 17 July 2017. Instagram post.”https://www.instagram.com/p/BWpfzQ8Au-w/?taken-by=kellyslater
- LaMontagne Mimi. The WSL Injury ListWhy it’s getting longer, and what it means for professional surfing. Surfline, Published:April 22, 2016.http://www.surfline.com/surf-news/why-its-getting-longer-and-what-it-means-for-professional-surfing-the-wsl-injury-list_137654/
- Furness, Hing, Abbott, et al Retrospective Analysis of chronic Injuries in recreational and competitive surfers: injury location, type and mechanism. IJARE. 2014: 8; 277-28.
4) Everline C. Shortboard performance surfing; A qualitative assessment of manoeuvers and a sample periodized strength and conditioning program in and out of the water. Strength Cond J. 2007; 29:32-40.
5)Barlow, Matthew John, et al. “Anthropometric and Performance Perspectives of Female Competitive Surfing.” Human Movement 17.3 (2016): 154-161.
6) Lundgren, Lina E., et al. “Comparison of impact forces, accelerations and ankle range of motion in surfing-related landing tasks.” Journal of sports sciences 34.11 (2016): 1051-1057.
7) Bruton, Michaela R., Roger D. Adams, and Nicholas J. O’Dwyer. “Sex differences in drop landing: more apparent in recreational surfers than in competitive surfers or nonsurfers.” Perceptual and motor skills (2017): 0031512517717853.