After picking my jaw up off the floor this week, I started processing the severity of what had happened to Kelly Slater’s 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. I will say that if there was a silver lining for Slater’s recent injury it’s 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 everything.
Kelly, if you have to break your metatarsals, this is a pretty eloquent way to pull it off.
All 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.
-Plantar fasciitis: 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 aches in the affected joints.
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. Additionally, other studies have identified screening tools and predictive factors for foot and ankle injuries in competitive male and female surfers. However, there is still a lacking connection between the 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. In a 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 recordings of our foot and ankle’s reactions to unanticipated surf conditions. This could record and give feedback via a waterproof watch or post-session. But, barring several (note, on the magnitude of 20) thousand dollars in development for something like this, (and more rainbows and butterflies), I have come up with some strategies to at least help surfers return to the water.
First, you have to take into consideration that every foot/ankle injury and recovery is different. These are considerations, not hard and fast rules.
1. Range of Motion
Not only are we talking about the injured joint itself, but above and below the site of injury too. Form follows function and each part of your foot has an important role in either stability or mobility. 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 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 brain’s 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 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 relay misinformation 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 which is used in the golf world to get better feedback about foot pressure/ posture.
-Crawling
-Rolling Patterns
3. Stretching
Consider what’s “tight” because it’s living in a constantly lengthened position versus 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:
-plantar fascia
-gastroc/ soleus complex
-hip extensors/flexors/rotators
4. Strengthening
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:
-resistive bands
-gym ball (think bridges or core stability)
-cable weights
-free weights
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:
-Total Gym
-Pilates Reformer
-RedCord Training
-Trampoline
-IndoBoard
-Agility Ladder
-Box Jumps
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. I wish him the very best with his injury recovery and healing process. That said, I think we’ve seen these types of foot and ankle injuries within the competitive aspect of surfing a lot. As we educate surfers, promote better technology for understanding and relating these types of injuries, we can create better preventative training programs, and hopefully limit some of these potentially career-ending type of injuries. Surfing will only continue to evolve with more aerial 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.
