The role of the podiatrist in injury prevention in football: theoretical approach and prospects for integration into the sports medical team

1. Introduction

Context: importance of football as a high-impact sport.

Relevance of the foot in performance and injury prevention.

Purpose of the thesis: to highlight the professional and clinical value of the podiatrist in competitive football.

2. Anatomical and biomechanical aspects of the footballer's foot

Anatomy and biomechanics of the footballer's foot

The foot is a complex and essential structure for the footballer, serving as both a support and an active organ in sports actions. In the upright position, the foot consists of 26 bones, 33 joints, and over a hundred muscles, tendons, and ligaments.
These bony structures are organized into three main regions: the tarsus, metatarsus, and phalanges.

Figure: main bones of the human foot (plantar, dorsal, and lateral sections), with tarsus (blue), metatarsus (orange), and phalanges (light green).

• Tarsus (hindfoot): includes the main load-bearing and weight-transferring bones. The tarsal bones are: talus, calcaneus, navicular, cuboid, and the three cuneiforms. These structures provide the bony foundation for the foot arches and contribute to shock absorption. The calcaneus, for example, serves as the insertion point for the Achilles tendon, important in running and jumping.

• Metatarsus: consists of five metatarsal bones; their arrangement and shape contribute to the forefoot rigidity during push-off.

• Phalanges (toes): the big toe has two phalanges, while the other four toes have three each. The metatarsophalangeal (MTP) and interphalangeal joints allow toe flexion and extension, essential in tiptoe strikes and balance.

The joints of the foot are numerous and allow complex movements to adapt to the ground. In addition to the talocrural joint (between tibia and talus), crucial for dorsiflexion and plantarflexion, there are the intertarsal joints (subtalar, talonavicular, calcaneocuboid) and tarsometatarsal joints. These structures enable pronation and supination of the hindfoot, essential for lateral adaptation during running and direction changes. Finally, the metatarsophalangeal and interphalangeal joints manage toe movements, completing the overall foot dynamics.

Figure: human foot musculature. (a) Superficial extrinsic dorsal muscles (lateral view); (b, c, d) three layers of plantar intrinsic muscles (plantar view). (From OpenStax).

The foot musculature includes extrinsic muscles (originating in the leg) and intrinsic muscles (contained within the foot). The main extrinsic dorsal muscles are the tibialis anterior, the long extensors of the toes and big toe, and the peroneals (fibularis) longus, brevis, and tertius . These control dorsiflexion of the foot and lateral stability during stance. The extrinsic plantar muscles include the triceps surae (gastrocnemius, soleus) and the long flexors of the toes and big toe, responsible for propulsion in plantarflexion. The figure illustrates the three layers of intrinsic plantar musculature: (b) superficial layer (e.g., abductor hallucis, flexor digitorum brevis), (c) intermediate layer (flexor digitorum brevis, quadratus plantae, lumbricals), and (d) deep layer (abductor digiti minimi, opponens, plantar/dorsal interossei). Intrinsic muscles, together with the plantar aponeurosis, maintain the arch and contribute to sole stability during locomotion.

Figure: plantar section of the foot (sole) highlighting the plantar aponeurosis and intrinsic muscles (highlighting abductor hallucis and plantar muscle bands). (From Sobo, 1909).

A key role is played by the plantar fascia (plantar aponeurosis) and intrinsic ligaments, which connect the bones and support the foot arches. Miralles and Miralles highlight that the combination of bony structure, plantar ligaments, and aponeurosis forms a solid static shock-absorbing system. This supportive “beam,” reinforced by adipose tissue and muscles, absorbs impact forces during ground contact. Specifically, the tension of the plantar fascia regulates the medial longitudinal arch: proper function improves elastic return during push-off. Biomechanical studies show that during kicking, ankle rigidity (fixed dorsiflexion) increases foot-ball contact area and thus ball speed. This underscores the importance of proper control of the plantar aponeurosis and plantar muscles in kick effectiveness.

The main neurovascular structures include the posterior tibial artery (branching into medial and lateral plantar vessels) and the anterior tibial artery (continuing as the dorsal artery of the foot). Key motor and sensory nerves are the tibial nerve (medial/lateral plantar branches) and fibular nerves (common, deep, and superficial peroneal) for the lower extremity. These nerve pathways innervate muscles and skin of the foot, enabling motor coordination and proprioception necessary for complex football motor patterns.

Biomechanics of athletic movements in football

Football involves numerous athletic movements in which the foot plays a decisive role. Each phase of athletic movement—running, jumping, kicking, direction changes, braking—imposes specific demands on the bones, muscles, and joints of the foot.

• Running: the gait cycle in football includes a support phase (stable on the ground) from heel strike to toe-off. Long-distance footballers show initial heel impact with slight supination, followed by pronation to absorb load, then reinversion of the foot arch in preparation for forefoot push-off. Sprinters impact almost exclusively on the lateral forefoot (“claw strike”), with the heel elevated. From a muscular perspective, propulsion occurs via knee and hip extension and strong plantarflexion (gastrocnemius, soleus): final speed depends on rapid plantarflexion at toe-off. Kenhub divides the support phase into five subphases (heel strike, foot flat, midstance, heel-off, toe-off), each with specific muscle activation. For example, eccentric tibialis anterior controls initial contact, while gastrocnemius and plantar flexors activate powerfully in the final push. Elastic energy stored in the plantar fascia and tendons (e.g., Achilles) is partially returned, improving step efficiency.

• Jumping: in vertical jumps, the foot is the last “gear” of the kinetic chain. Take-off occurs mainly in plantarflexion on the forefoot with full knee/hip extension, exploiting the elastic component of the triceps surae. In contrast, landing involves dorsiflexed foot position, with impact absorbed by quadriceps (eccentric contraction) and dynamic inversion of the foot arch. Studies indicate quadriceps reach high activation levels during landing (over 160% of maximal voluntary contraction) to dissipate kinetic energy. Proper jumping technique controls pronation immediately after impact, reducing excessive stress on ankle and knee.

• Kicking: the kick is multi-joint and synergistic. The support leg absorbs weight and stabilizes the body, while the kicking leg performs a wide backswing followed by rapid hip and knee extension. A functional proximal-to-distal sequence has been observed: the hip extends first while the knee is flexed, then the knee extends rapidly, transferring momentum to the foot. At foot-ball impact, foot angular velocity peaks, coinciding with near-complete knee extension. Foot dynamics (kept nearly rigid in dorsiflexion) maximize contact area with the ball: experimental data show broader contact increases ball speed. Essentially, achieving powerful kicks requires high foot speed through coordinated trunk, hip, knee, and ankle sequencing. Instep kicks also require angled foot positioning (supination or pronation) to direct the ball, engaging intrinsic muscles for stabilization and tibials for fine adjustments.

• Direction changes and braking: football involves rapid accelerations, decelerations, and changes of direction. In braking (horizontal deceleration), the foot acts as a brake: often the forefoot or heel is used to stop motion. Recent studies highlight that high-intensity decelerations are common in football and have unique biomechanical characteristics (very high force peaks). Key for quick direction changes is the ability to dissipate load effectively: literature defines the penultimate step as a “braking step” preparing for final deceleration. During unexpected maneuvers, the foot may contact with the heel (heel strike), unlike acceleration running which favors the forefoot. This postural transition reduces tri-axial knee loads but creates high rate-of-change of velocity. Additionally, in the final braking step, tibialis anterior activates strongly to control dorsiflexion, while quadriceps work eccentrically with very high activation (up to ~160% MVC). In summary, intense decelerations generate greater ground reaction forces than acceleration, making specific eccentric strength and technique training crucial. Training the knee and ankle to absorb peak forces has been proposed as an “injury-prevention vaccine,” preparing athletes to withstand repeated braking stress.

Biomechanical impact on performance and injury prevention

Anatomical and biomechanical characteristics of the foot directly influence sports performance and injury susceptibility. A well-functioning arch (neither too flat nor too high) allows storage and release of elastic energy like a spring, improving sprinting and jumping efficiency. For example, high foot stiffness (rapid plantarflexion) is associated with better speed performance. Conversely, misalignments or structural overloads impair mechanical adaptation: an overpronated foot induces internal tibial rotation and may predispose to conditions like plantar fasciitis, medial tibial stress syndrome, and patellofemoral pain. Footballers often report plantar pain consistent with fasciitis, even if not clinically diagnosed. Other common foot injuries in football include sprains, contusions, and impact fractures; video analysis shows most originate from lateral contact (tackles) causing forced inversion or eversion.

For prevention, it is crucial to strengthen foot muscles (tibials, peroneals, intrinsic) to stabilize arches and modulate impact forces. Footwear and foot alignment also play a role: for instance, rigid football boots with studs increase tension on the sole and Achilles tendon, so cushioned insoles or anatomically shaped shoes can mitigate these effects. Literature suggests that the efficiency of the foot's shock-absorbing system (bones, ligaments, aponeurosis) is critical to protect the upper kinetic chain from repeated overloads. In general, developing specific preparation (plyometric exercises, flexor stretching, neuromuscular training) aims to optimize the biomechanical contribution of the foot to performance and reduce the risk of acute and overuse injuries.

Comparative tables

3. Main podiatric pathologies in footballers

Footballers’ feet are subjected to repeated mechanical stress: running, sprinting, abrupt direction changes, frequent heel pushes, and forefoot loads. These stresses, combined with tight football boots and playing surfaces (natural or synthetic), favor the onset of various podiatric disorders. Among the main foot pathologies in athletes are:

• Plantar Fasciitis (Heel Pain) This is a chronic inflammation of the plantar fascia, the strong aponeurosis that supports the medial longitudinal arch. Fasciitis causes inferomedial heel pain, typically upon waking or after prolonged loading. It is one of the most common foot conditions (affecting about 3–7% of the general population and over 10% of runners), and sports with frequent heel loading (running, jumping, and even football on hard surfaces) are particularly at risk. Predisposing factors include biomechanical abnormalities of the foot (pronated or high-arched foot, limited ankle dorsiflexion) and inappropriate footwear. The impact on performance is significant: pain reduces ground push-off ability and limits running and kicking technique. The podiatrist intervenes by assessing gait mechanics and the arch (e.g., via baropodometric examination), recommending calf stretching exercises, and prescribing custom insoles or cushioning pads to better distribute pressure and reduce fascial stress.

 

Figure: Anatomical view of the plantar fascia (in yellow) and areas of inflammation from plantar fasciitis .

• Ingrown Toenail (Onychocryptosis). Primarily affects the big toe. An ingrown toenail occurs when the nail edge embeds into the periungual groove, causing a small often inflamed wound. Anatomical causes include excessive curvature of the nail plate (“tile” shape), but the main triggers are microtraumas (repeated impacts to the forefoot) and improperly fitting football shoes. Amateur and professional players may develop ingrown toenails due to tight boots and repetitive contact trauma. Inflammatory swelling of the toe and possible infection (subungual hematoma) lead to severe pain, swelling, and redness, interfering with athletic performance. The podiatrist’s role is essential: during the acute phase, the ingrown portion of the nail is removed and the area treated locally, immediately relieving pain. Later, proper nail care habits are recommended (cutting straight across, avoiding excessive trimming of the white edge) along with protective barriers (silicone pads). In some cases, the podiatrist may apply small orthotic supports or, if necessary, perform a minimally invasive procedure to remove the protruding nail portion and prevent recurrence.

Figure: Schematic evolution of ingrown toenail in three stages: normal nail, initial ingrowth, secondary infection .

• Metatarsalgia. Clinical condition characterized by plantar pain in the metatarsal heads (forefoot), often called “metatarsal load syndrome.” Pain increases with running, jumping, and prolonged walking, often described as “walking on stones.” Main causes include repeated forefoot overload due to anatomical abnormalities (flat or high-arched foot, hallux valgus, hammer toes) and/or biomechanical defects (overpronation, limited dorsiflexion). Stiff or tight football shoes also increase pressure on the metatarsal heads. Although specific data for footballers is limited, metatarsalgia is common in athletes with intense training. Functionally, it causes pain during plantar roll-off and reduces foot propulsion, potentially altering posture and running technique. The podiatrist intervenes by adding metatarsal pads and lifts in insoles to elevate the metatarsal heads and redistribute loads, also recommending shoes with more forefoot space and cushioning. Biomechanical analysis helps identify and correct gait imbalances (e.g., excessive pronation) that overload the forefoot.

• Tendinopathies (e.g., Achilles). The foot and ankle tendons, particularly the Achilles tendon, are at risk due to the repeated accelerations, decelerations, and pushes typical in football. Achilles tendinopathy manifests with pain and swelling along the tendon, often at the midsection or heel insertion. It is caused by functional overload: intense training, repeated accelerations, and sudden movements impose high stress on the tendon. Predisposing factors include overweight, hard surfaces, and excessive calf stretching (limited dorsiflexion). Incidence in youth football is high (about 20–25 cases per 100 university athletes studied) and can become chronic if not properly treated. Pain limits heel push-off, compromising propulsion and increasing long-term rupture risk. The podiatrist collaborates by prescribing stretching and eccentric exercises for the triceps surae complex, using heel lifts if needed to reduce Achilles tension, and monitoring gait and plantar pressure distribution.

• Plantar Warts (Papillomatosis). Thickened skin growths caused by HPV infection localized on the sole. Simple plantar warts, the most common, appear yellowish and rough, often with small “black dots” (microhemorrhages) on the surfacef. They are painful under pressure and when walking. Favoring factors include micro skin injuries and the warm, humid environment of locker rooms and showers, where the virus spreads easily barefoot. In footballers, sweat and foot trauma facilitate their appearance. Functionally, plantar warts make weight-bearing painful and may reduce propulsion. The podiatrist can treat them with topical remedies (e.g., salicylic acid) or cryotherapy, safely removing viral tissue; protective foam or silicone pads are recommended to reduce pressure during load, along with hygiene instructions to prevent spread (dry feet thoroughly, avoid direct contact with shared surfaces).

Figure: Painful plantar wart (dark central area) on the big toe of a footballer undergoing podiatric examination .

• Calluses and Corns. Calluses (or corns) are skin thickenings caused by excessive and repeated friction or pressure. They frequently appear at high-load areas (metatarsals, heel) or between toes. In footballers, metatarsal calluses result from constant forefoot pressure, and heel calluses from improper footwear. Tight shoes or worn studs increase local pressure. Unlike painless calluses, corns can become sensitive and impair walking, altering posture. The podiatrist regularly removes these thickened areas (with sterile file or rasp) and recommends soft insoles or air chambers to offload pressure points. Anatomical abnormalities (e.g., hallux valgus or overlapping toes) are corrected to prevent recurrence.

Risk Factors (Predisposing). Causes of these conditions are typically multifactorial. Biomechanical factors include excessively pronated or supinated foot, flat or high-arched foot, hallux valgus, hammer toes, and limited ankle/knee dorsiflexion. These anomalies alter plantar load distribution, overloading fascia, tendons, or metatarsals. Environmental factors include training intensity and frequency, very hard or artificial fields, and cold or humid conditions (which weaken skin, facilitating microtraumas and viral infections). Equipment factors include inadequate footwear: overly tight football boots, worn studs, or non-cushioned training shoes increase microtrauma. Tight shoes promote ingrown nails and calluses, while inappropriate footwear can trigger fasciitis or metatarsalgia (as also observed in runners and footballers).

The Role of the Podiatrist in Prevention, Diagnosis, and Treatment

The podiatrist is a key figure in reducing the incidence and impact of these conditions in athletes. In the prevention phase, they conduct functional screenings (e.g., baropodometric analysis, assessment of stance and kinematic chain) to identify biomechanical imbalances or joint limitations. Based on this, they recommend targeted strengthening and stretching exercises (e.g., soleus/gastrocnemius stretching to improve dorsiflexion), appropriate technical footwear, and, if needed, custom insoles that correct foot defects or protect high-risk areas. In diagnosis, the podiatrist performs focused clinical exams: for example, the Silfverskiöld test (to evaluate foot dorsiflexion with knee flexed/extended) helps determine the origin of fasciitis, while nails and skin are inspected for calluses, corns, or warts, assessing nail health. For suspected deep lesions, instrumental exams may be used (ultrasound for fasciitis, microbiological analysis for infection). Finally, in treatment, the podiatrist applies specific therapies: preparing insoles with supports (metatarsal pads, heel lifts), removing calluses with sterile tools, treating ingrown nails, or stabilizing them after fragment removal. They may also prescribe physical or topical therapies (e.g., local anti-inflammatory relief, cryotherapy for warts) and collaborate with the rehabilitation team to ensure athletes follow appropriate functional recovery protocols. In this way, the podiatrist not only treats existing injuries but also works preventively to maintain optimal foot function.

4. The Role of the Podiatrist in the Sports Medical Team

The athlete’s foot is the primary support point during training and competition: every technical movement, from changing direction to running propulsion, depends on its correct function. Sports podiatry addresses foot problems related to athletic activity. The sports podiatrist is therefore specialized in preventing and treating foot-related injuries, aiming to reduce downtime due to injuries and optimize performance. In a professional football team, this healthcare professional works comprehensively: from the athlete’s initial check-up to post-injury recovery, including optimizing the athletic movement through targeted biomechanical solutions.

Roles and Functions of the Podiatrist

In a professional team, the podiatrist performs key roles in screening, functional assessment, treatment, and rehabilitation. They conduct in-depth biomechanical evaluations of the foot and gait to identify imbalances or anomalies that may predispose to injuries. In prevention, the podiatrist regularly monitors athletes (e.g., baropodometric analysis of plantar load) and recommends custom footwear or orthotics to reduce mechanical overload. For acute injuries (ankle sprains, tendinitis, blisters, nail trauma, etc.), the podiatrist intervenes with local therapies (e.g., functional taping, mobilization exercises) in collaboration with the physiotherapist. For chronic injuries (plantar fasciitis, metatarsalgia, Morton’s neuroma, overload syndromes), they design rehabilitation plans and custom orthoses to ensure safe return to activity. The main objectives are to improve posture and plantar support, prevent recurrence, and optimize the athlete’s technical performance.

• Prevention: biomechanical screening (running and posture analysis) and correction of defects (e.g., with custom insoles) to reduce the risk of overload injuries.

• Functional Assessment: instrumental exams (baropodometry, gait analysis) and clinical tests to measure stability, foot support, and relationships with ankle, knee, and spine.

• Treatment: management of acute and chronic foot/ankle conditions (heel pain, tendinopathies, nail disorders, skin lesions) through podiatric and orthotic therapies, and, if necessary, integration with other therapies (physiotherapy, tecar, laser).

• Functional Rehabilitation: development of recovery protocols including specific exercises (e.g., proprioceptive or foot strengthening) and monitoring return to play, addressing both symptom and cause to prevent recurrence

  

Collaboration with Other Healthcare Professionals

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  In athlete care, the podiatrist works in a team with sports physician, physiotherapist, and athletic trainer. Typically, the team doctor oversees the athlete’s overall health and relies on the podiatrist for foot or posture-related issues. The physiotherapist is essential during rehabilitation, integrating podiatrist-prescribed exercises and applying manual or instrumental therapies. The athletic trainer coordinates workouts and integrates the podiatrist’s guidance (e.g., muscle strengthening or proprioceptive exercises) to prevent future injuries. As highlighted by Valencia CF podiatrist Carme Viel, “it’s a team effort, never said better”: each professional must establish trust with the athlete and the rest of the staff to maximize intervention effectiveness.

  • Sports Physician: coordinates fitness evaluations and manages clinical emergencies; the podiatrist alerts the doctor to systemic conditions (e.g., diabetes) or chronic foot pathologies.

  • Physiotherapist: co-designs post-injury rehabilitation; adapts functional exercises and physical therapies (magnetotherapy, ultrasound, therapeutic exercises) per the podiatrist’s guidance.

  • Athletic Trainer: oversees athlete training; incorporates podiatrist-recommended exercises (e.g., specific proprioceptive or knee/ankle strengthening activities) to prevent long-term relapse.

  • Other Specialists: the podiatrist may also liaise with orthopedic surgeons, nutritionists, or sports psychologists when complex conditions exist (e.g., spinal issues related to foot posture) requiring a multidisciplinary approach.

Types of Podiatric Intervention

The podiatrist has various diagnostic and therapeutic tools. In standard biomechanical assessments, baropodometric platforms and 3D gait analysis systems are used to measure plantar pressure distribution and gait kinematics. These exams identify imbalances (e.g., excessive pronation) that can be corrected. In acute injuries (e.g., Achilles tendinopathy or ankle sprain), the podiatrist provides immediate first aid (taping, protective bandages) and collaborates on the rehabilitation program. For chronic foot conditions in footballers (plantar fasciitis, metatarsalgia, neuroma, repetitive nail disorders), the approach is multidisciplinary: targeted physiotherapy and, when needed, specific podiatric treatments (corn decompression, ingrown nail care, etc.) are applied.

• Instrumental Assessments: static/dynamic analysis on stabilometric platforms and computerised baropodometry to study gait phases and plantar load.

• Custom Orthotic Prescription: thermoplastic or EVA insoles made layer-by-layer to support the arch and correct foot stance. These devices realign the skeleton to the ideal position, evenly distribute pressure, and reduce localized overloads, helping prevent injury recurrence.

• Podiatric Treatments: management of acute (blisters, ingrown nails, small cuts or wounds) and chronic conditions (hyperkeratosis, calluses, plantar warts). For plantar fasciitis, physical therapies (ultrasound, laser) can be combined with stretching exercises and supportive insoles; for metatarsalgia or neuroma, plantar offloading with custom orthoses is applied.

• Functional Rehabilitation: after a sports injury, the podiatrist provides protocols for muscle strengthening, balance control, and gait restoration. Techniques such as kinesio-taping or targeted exercises are used to reassess foot posture dynamically.

• Athlete Education: practical advice on choosing appropriate sports footwear (suited to foot type and activity) and hygiene strategies (skin care, infection and friction injury prevention). Athletes are instructed to promptly report any foot discomfort (from simple heel pain to nail changes) to address issues before they worsen.

The figure illustrates the adaptation of a custom insole: the technician is shaping a personalized insert to be placed in the player’s shoe. This example highlights how the insole is a key intervention to realign the foot and evenly distribute load during athletic movements, improving posture and reducing stress on the heel and forefoot.

Practical Examples and Organizational Models

In professional settings, podiatrists are increasingly integrated into the medical staff of football teams. In Italy, for example, the FIGC has historically included specialist figures: Dr. Pierluigi Gennari served as the national team podiatrist (from 1998 to 2016) and today collaborates with Serie A clubs such as AC Milan, Juventus, and Monza. Institutions like the MilanLab center also employ podiatrists to manage foot health in their performance protocols. In Spain, the importance of podiatrists is recognized at the federal level: as reported by the San Agustín hospital, “todos los clubes cuentan con un Podólogo en su plantilla” to address the high number of foot injuries among players. For example, Valencia CF and Levante UD have in-house podiatrists (Carme Viel, Santiago Muñoz) who actively collaborate with coaches and medical staff on preventive measures. In the United Kingdom, similarly, federations and Premier League clubs regularly assign a podiatrist to the team: the Royal College of Podiatry notes that “a club podiatrist sees all players regularly” and is an essential member of the medical staff. In these international contexts, podiatrists contribute to implementing injury prevention plans based on foot care, working with physiotherapists and athletic trainers to keep athletes on the field longer and performing at their best.

5. The Podiatrist in Football: International Experiences and Integration Models

• Overview of how podiatrists are included in sports teams in Spain, the United Kingdom, Argentina, etc.

• Best practices and official guidelines (e.g., FIFA, football federations).

• Differences with the Italian context: regulatory limits and development opportunities.

6. Conclusions

• Summary of key points.

• Recognition of the podiatrist as an essential figure in sports medicine.

  Proposals for greater integration of podiatry in professional and amateur football

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Chapter 4

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Chapter 5

Conclusions