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Understanding The Field Hockey Athlete: A Podiatric Primer
High-level field hockey is a relatively uncommon sport in the United States. Internationally, however, it draws many spectators and provides the same excitement and competition that characterizes sports popular in the U.S. It is a fast, high-contact sport filled with intensity. Field hockey is most popular in the eastern hemisphere, with India considered a long-standing powerhouse with considerable following. Belgium is currently top-ranked and may overtake India in popularity as overall interest in European countries soars.1 The following is an introduction to the sport and vital concepts for treating field hockey injuries that may present in your practice.
Both men and women play field hockey, believed to originate from earlier civilizations, at recreational and professional levels worldwide. Men’s field hockey is an Olympic sport that participated in the rescheduled 2020 Olympics in Tokyo this summer.2 The game involves two opposing teams of 11 players each.1 Injuries trends in field hockey are similar to other high-impact sports. Studies show that the majority of injuries sustained by women during major tournaments were to the head. Other injuries include contusions, hematomas, abrasions due to players’ contact with the ball, stick, or playing surface.2 This article, however, will focus on common lower extremity injuries one may sustain participating in field hockey.
Common Podiatric Pathologies Experienced By Field Hockey Athletes
It is important to examine lower extremity field hockey injuries in terms of the phases of the injury. This may include acute, subacute, and rehabilitation phases. In our experience, the below injuries and conditions are commonly experienced by these athletes.
Tibialis Anterior and Tibialis Posterior Tendonitis. Tibialis anterior and tibialis posterior tendonitis are common overuse injuries in field hockey athletes. Protection, rest, ice, compression and elevation (PRICE), isometric exercises, gastro-soleal stretching, and ultrasound therapy are some possible modalities to address this pathology. In the subacute phase, emphasis on flexibility, isometric exercises with TheraBand,® and balance activities can prove beneficial. The return-to-sport phase begins with proper warm-up and stretching. Running may resume but only to the extent of a pain-free schedule and avoidance of uneven surfaces, which exert relatively high impact on various joints.3
Ankle Sprains. In the acute phase, these injuries generally manifest in edema and pain. Protective or functional bracing, depending on the grade of ankle sprain, can be useful. In our experience, a grade 1 ankle sprain might benefit from a brace such as a more functional ASO brace. However, for grade 2 and 3-type sprains athletes may initially require immobilization in a protective brace such as a CAM boot before progressing to a more functional ASO-type brace. The subacute phase of such sprains should then progress into rehab with increasingly pain-free range of motion followed by strength training. Proprioceptive training to assist with mechanical and functional stability is ideal during this phase. The rehabilitation phase often results in a further increase in range of motion, continued strengthening, and increased pain-free activities of daily living at full weight-bearing.4
Stress Fractures. Stress fractures are not always obvious. One may think of these as overuse injuries on normal bone, or due to insufficiency of bone with regular activity. For female athletes, there can exist an associated triad of low energy availability, with or without disordered eating, menstrual dysfunction, and low bone mineral density. This phenomenon is common in teens especially. This places young females at greater risk of developing injuries, especially stress fractures in field hockey due to overactivity, body factors affected by the above triad, or a combination of the two. When a stress fracture occurs in any athlete, it is important to limit activity and weight-bearing. The PRICE protocol along with a surgical shoe or CAM boot for immobilization can be helpful, typically when employed for about two weeks. If left untreated, these stress fractures could develop into a worsening fracture that could eventually lead to a nonunion. This would result in a longer healing process and more time away from the sport, which is significantly detrimental to higher-level athletes.5
Chronic Ankle Instability. This pathology affects athletes with a cavovarus foot structure or a chronic history of ankle sprains. A study by Kim and colleagues looked at elite female field hockey players and how neuromuscular training can affect rearfoot angle kinematics.6 Original participants included 25 elite female Korean field hockey players who sustained an ankle inversion injury one year prior to the study and had at least one day of interrupted participation in sport along with a feeling of instability in the affected ankle. Researchers excluded cases of complete rupture, medial ankle instability, subtalar joint instability, bilateral ankle instability, syndesmotic injury, or spring ligament injury.6 This left 21 subjects, 12 with chronic ankle instability for the experimental group and nine without instability in the control group. The experimental cohort underwent baseline measurements, six weeks of neuromuscular training, and new measurements at six- and 24-weeks. The measurements included ankle position at heel strike, midstance, and toe touch in the frontal plane during walking, running, and landing using 3D motion analysis. Those with chronic ankle instability had more ankle inversion at heel strike and midstance and, after training, more eversion at six weeks. However, at 24 weeks, ankle position returned to baseline. This ultimately suggested that neuromuscular training can immediately have a short-term impact on chronic ankle instability in field hockey players.6 However, further studies that continue this training for longer are necessary to determine benefit to athletes with chronic ankle instability over time.
Pes Planus. For athletes with pes planus, their gait and foot type predisposes them to increased risk for various injuries and overuse pathologies. There are several ways to assist in injury prevention. One preventive option is using various orthotic devices which can help support a decreased medial arch and everted rearfoot. Ng and team looked at pre-fabricated orthotics versus sham in sprinting athletes with pes planus.7 The study found that pre-fabricated foot orthoses led to an increase in the vertical loading and step-to-step kinetic variability at sprint speeds of five to seven m/s compared with a sham insole. Athletes did have greater support along the medial arch but less comfort and cushioning with the pre-fabricated orthosis when performing moderate-to-fast sprints.7
Pes planus can be challenging as this foot structure can lead to various injuries, especially some overuse pathologies such as posterior tibial tendinitis, anterior tibial tendinitis, and stress fractures. Field hockey players may relate that a pre-fabricated orthotic be more comfortable and provide more support for them. Podiatrists may find it useful to get field hockey athletes into a pre-fabricated orthotic preventatively so as to hopefully improve the biomechanics of the athlete and prevent some injuries which could occur.
Considering The Psychological Impact Of Injury In Return To Play
A care provider must also keep in mind the mental and emotional aspects of an athlete’s return to activity. In a study published this year, 25 injured male national team-level field hockey players (average age 25.37 years) underwent assessment using the Self Confidence Scale (SCS) regarding returning to the field of play.8 This scale, developed by Yadav and Bajpai in 2015, consists of 20 questions, each on a five-point scale. The reliability coefficient of this scale is 0.79, and the construct validity coefficient was 0.69. The authors then stratified these athletes based on scores of how confident the athletes were psychologically returning to play. These stratifications included high-level, average-level, and low-level of confidence based on a self-reported questionnaire. The high-level score was greater than 65, average-level between 47 and 65 and low-level less than 47 regarding confidence when returning to play. They found that 44 percent of subjects had high-level confidence, 44 percent average-level, and 12 percent low-level confidence in returning to play.8 There was no statistically significant differences between the athletes’ levels of confidence, and it is unclear as to why some were less confident in returning to play after injury. The authors hypothesized that not only do athletes focus on the physical rehabilitation when returning to sport, but that there is also a psychological component when returning to sport and this can affect the athletes in various ways. Anxiety over reinjury or returning to a high-level standard of play could be factors. They also added that perceived expectations of the coach, teammates, family, and fans could weigh on players, causing trepidation in returning to the sport. The authors of the paper conclude that, along with physical rehabilitation programs, good psychological rehabilitation could prove helpful in returning to sport after an injury.8
Final Thoughts
In our experience, it behooves podiatrists to prepare for a rise in popularity of field hockey, and a possible rise in resultant patient visits due to lower extremity issues experienced by these athletes. By familiarizing oneself with the intricacies of the sport, one may better understand the mechanics necessary to succeed in field hockey and apply one’s podiatric knowledge to supporting the athlete’s trajectory.
Dr. Haley is the Chief of the Podiatric Surgical Service at Christiana Care Health System in Delaware. He is a Fellow of the American College of Foot and Ankle Surgeons, the American Society of Podiatric Surgeons, and the American Academy of Podiatric Sports Medicine.
Dr. Boissonneault is a second-year Podiatric Medicine and Surgery Resident at Christiana Care Health Services in Delaware.
Dr. Nguyen is a recently graduated Podiatric Medicine and Surgery Resident at Christiana Care Health Services in Delaware, now affiliated with the VA Health System in Sioux Falls, S.D.
Dr. Green is a third-year Podiatric Medicine and Surgery Resident at Christiana Care Health Services in Delaware.
1. Field Hockey. Brittanica website. Available at: https://www.britannica.com/sports/field-hockey. Published April 2021. Accessed September 2, 2021.
2. Barboza et al. Injuries in Field Hockey players: A Systematic Review. Sports Medicine. 2018: 48(4):849-866.
3. Posterior tibial tendon dysfunction. Foot Health Facts website. Available at: https:// www.foothealthfacts.org/conditions/posterior-tibial-tendon-dysfunction-(pttd) . Accessed September 8, 2021.
4. Ankle sprain. Foot Health Facts website. Available at: https://www.foothealthfacts.org/conditions/ankle-sprain . Accessed September 2, 2021.
5. Nose-Ogura A, Yoshino O, Dohi M, et al. Risk factors of stress fractures due to the female athlete triad: Differences in teens and twenties. Scand J Med Sci Sports. 2019;29(10):1501-1510.
6. Kim E, Choi H, Cha JH, Park JC, Kim T. Effects of neuromuscular training on the rear-foot angle kinematics in elite women field hockey players with chronic ankle instability. J Sports Sci Med. 2017;16(1):137-146.
7. Ng JW, Chong LJY, Pan JW, Lam W-K, Ho M, Kong PW. Effects of foot orthosis on ground reaction forces and perception during short sprints in flat-footed athletes. Res Sports Med. 2021;29(1):43-55.
8. Singh RK, Yada JS, Bajpai S. Effect of sports injury on self-confidence of national male hockey players. Int J Phys Ed Sports Health. 2021;8(1):228-230.
