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FOOT AND ANKLE INJURIES IN CRICKET : A

REVIEW
DATASET OCTOBER 2008

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J of Foot and Ankle Surgery XXVI (2) Dec 2011

Foot and Ankle injuries in Cricket : A Review

FOOT AND ANKLE INJURIES IN CRICKET : A REVIEW

Prof. Mandeep S. Dhillon, Dr. Sharad Prabhakar, Himmat Dhillon, Dr. Vikas Bachhal
Deptt. of Orthopaedic Surgery PGIMER Chandigarh. 2Deptt of Physiotherapy, Govt. Multi-Specialty Hospital, Sec 16,
Chandigarh
Corresponding Author : Prof. MS Dhillon, e-mail : drdhillon@gmail.com

40 overs, and now the sudden burst of intense physical

activity that is twenty/20 cricket

Abstract : Cricket is undoubtedly the most popular sport

in India. It is a major international sport played in more
than 60 countries. Although termed a non-contact sport,
injuries in cricket are fairly common. Despite its popularity,
the review of the cricket injury literature shows that only
five major cricket-playing countries, namely England, South
Africa, Australia, New Zealand and W est Indies have
collected data on injuries sustained in cricket. Very limited
data is available from the sub-continent, which has now
become the hub of all cricket related activities. There have
been relatively few publications in the medical literature
on cricket injuries and fewer still that have been focused
on foot and ankle injuries. Injury definitions were poorly
defined before Orchard et al laid down guidelines for what
would be considered as a cricket injury. The present article
reviews the literature on foot and ankle injuries in cricket.

Despite its presumed popularity in many regions

of the world, a recent editorial explaining the game
of cricket itself in the Journal of Science and Medicine
in Sport, (with that same issue containing two articles
related to cricket) clearly shows the lack of published
data and limited research on the subject of science
and medicine in cricket [1].
Injuries will happen in all sports, and cricket is
no different. Although termed a non-contact sport,
injuries in cricket are fairly common, and have been
documented as far back as 1751, when Frederick,
Prince of Wales (son of George II), expired suddenly
from an abscess in his head as a consequence of a
blow he had received from a cricket ball [2]. Despite
being one of the more popular team sports in countries
of the former Commonwealth, there have been
relatively few publications in the medical literature
on cricket injuries and fewer still that have been
focused on foot and ankle injuries. Injury definitions
were poorly defined before Orchard et al laid down
guidelines for what would be considered as a Cricket
injury, and this is now the standard for usage in injury
surveillance and documentation (and was a first
attempt of its kind for any sports injury) [3]. Their
definition defines a cricket injury as any injury or
other medical condition that either: (a) prevents a
player from being fully available for selection for a
major match or (b) during a major match, causes a
player to be unable to bat, bowl or keep wicket when

Key Words : Cricket-sport-foot and ankle-injury.

Introduction
Cricket is undoubtedly the most popular sport in India.
It is a major international sport played in more than
60 countries. The first recorded international took
place in 1844, at St Georges Park, New York,
between the United States and Canada; Canada won.
The inaugural test match was played between
Australia and England at the Melbourne Cricket
Ground in 18771. Test Cricket, played over 5 days,
was considered a laid back sport, with limited contact
between players, and limited potential for injury
during the game. However there has been a significant
evolution of the game from the languor of Test
Cricket, to the hectic tussle between two teams over

J of Foot and Ankle Surgery XXVI (2) Dec 2011

Foot and Ankle injuries in Cricket : A Review

required by either the rules or the teams captain.

that the proportion of injuries to the lower limbs has

increased steadilyover two decades, while there was
a discernable drop in injuries to the upper limbs.
Injury proportion of upper limbs decreased from
34.1% (in 1993) to 23.3% reported in 2003 while
during the same period proportion of lower limb
injuries increased from 37.5% to 49.8% [5, 7]. As
injuries to upper limbs or head and neck area are
generally impact injuries sustained in the game, as
opposed to injuries to lower limbs or back and trunk
which are generally overuse injuries, this change in
injury pattern might indicate effective measures in
improvement of protective equipment and perhaps
reflects the changing nature and increased volume of
game putting more demand on lower limbs and trunk.
Of note is the fact that during this period the
proportion of injuries to head and neck area and trunk
was noted to have remained same. In 2005 report
from South Africa [8], 1,606 injuries in 783 cricketers
were reported prospectively by the physiotherapists
and doctors working with the national and 11
provincial teams over a 6-season period.Lower limb
injuries accounted for nearly half of the injuries
(49%); bowling (40%), fielding and wicket-keeping
(33%) accounted for the majority of the injuries.

The present article reviews the literature on foot

and ankle injuries in cricket. Paucity of data regarding
injuries to foot maybe either due to less injuries
happening to the foot (which is untrue), or a reflection
of the ability of players to cope with or recover from
foot injuries, or might indicate the lack of significance
given to these injuries by the players and the treating
staff.

Foot and Ankle injury epidemiology in cricket

Despite its popularity, the review of the cricket injury
literature shows that only five major cricket-playing
countries, namely England, South Africa, Australia,
New Zealand and West Indies have collected data on
injuries sustained in cricket. Very limited data is
available from the sub-continent, which has now
become the hub of all cricket related activities.
In the British study [4], injury information was
obtained retrospectively from the records of the team
physiotherapist for the 54 cricketers who had played
for the same county team in England between 1985
and 1995. In this study the term injury was defined
as the onset of pain or disability caused while training
for or playing cricket and which caused the player to
seek medical attention. A total of 990 injuries were
recorded, with an injury exposure of 17,247 days
played and an injury incidence rate of 57.4 injuries
per 1,000 days played. Most injuries occurred to the
lower limbs (44.9%) with calf and thigh (24.6%),
knee (9.9%) and foot and ankle as major sites (8.7%).
The primary foot and ankle injuries were contusions/
haematomas (41%) and ligament/joint sprains (29%).

Orchard et al published their report on incidence

and prevalence of cricketing injuries during 10
consecutive seasons from Australian state and national
teams [9]. This study was unique in following the
new injury definitions and presenting long-term data
for elite cricketers [3]. The injuries were sustained
while bowling (45%), batting (21%), fielding (23%)
and wicket-keeping (2%).Lower-limb injuries
accounted for nearly half of the injuries (49.1%).
The incidence of injuries to shin/foot/ankle area was
consistently ranked in three most frequently injured
anatomical sites accounting for 17% (range 10.9%23.8%) injury incidence while injury prevalence was
similarly high for this site.

In studies reported fromSouth Africa(all done by

Richard Stretch and associates), the injury incidence
has been documented serially from 1993 to 2005 [5,
6, 7, 8]. Although these reports did not elaborate on
foot and ankle injuries, they reported on incidence of
injuries to lower limb over several different seasons.
An interesting fact that emerges from these reports is

From the West Indies, Mansinghet al reported

injury rates from single season in West Indian cricket
9

J of Foot and Ankle Surgery XXVI (2) Dec 2011

Foot and Ankle injuries in Cricket : A Review

based on the internationally agreed definitions of

injury in cricket [10]. This report was the first to
have been published using the new definitions of
Cricket injury. They reported only one case of ankle
sprain and two injuries to tibial region amongst 50
recorded injuries;this amounts to 6% injuries as
compared to an average of 17% injuries for similar
anatomical site in the report of Orchard et al [10].
These differences might reflect differences in the type
of playing grounds, the level of athleticism, and
general nature and pace of the game in these two
countries. Nevertheless a direct comparison cannot
be drawn between these two studies as the Australian
study encompassed a full decade as compared to a
single season in the West Indian report.

which may no longer apply to many teams who play

all round the year. The relevance of this maybe
reflected in another interesting fact reported by several
authors; a higher incidence of injuries has been noted
during pre-season, early season and end of season
but these reports did not comment on the nature and
anatomical sites of injuries during these various stages
of the so called season [4, 5, 6].
Direct injury to the foot is uncommon but is
often seen when the ball directly hits the foot.Fast
bowler Brett Lee was diagnosed with a broken foot
following a fielding incident in a T20 international
against India at the MCG. Cricket Australia team
Doctor Trefor James said: Brett Lee sustained a
fracture of his right foot when he was struck by a
ball in the last over of his spell during the KFC T20
against India at the MCG on Friday night.

Recently Walker et al reported on cricket

associated injuries in New Zealand [11] which is in
a unique position in that financially they have fairly
scant resources to support additional surveillance at
the elite level, yet at amateur level they have the best
infrastructure of all nations due to the existence of
the Accident Compensation Corporation and National
Minimum Data Set of public and private hospital
discharges and day patients [9, 11, 12]. Their injury
definitions included those who required atleast
overnight hospitalization. They reported the highest
incidence of injuries in upper (36%) and lower (31%)
limbs. Moreover, almost one third (n = 44) of lower
limb injuries were to the Achilles tendon, due to
overexertion and strenuous or repetitive movements
causing a sprain or strain (n = 37) or rupture/ tear (n
= 7). Similar numbers of injuries were sustained by
the tibia/fibula (n = 27), the ankle (n = 25), and the
knee (n = 21). Fewer injuries were to the femur (n
= 15) and foot (n = 10) while 3% of all injury was
noted in the trunk and back. Overall, 79 of 156
injuries (50.6%) to the lower limb were sustained in
the area of foot and ankle (including Achilles tendon).
Patients aged 30-39 years were especially susceptible
to Achilles tendon sprain/strain.

Fig.-1:

Cricket officially has a season and an off-season,

10

Brett lee with broken Toe. (Photo & report, Sydney Morning
Herald).http://www.smh.com.au/sport/cricket/speedster-brettlee-suffers-broken-foot-20120205-1qzed.html#ixzz214rlDjgE

J of Foot and Ankle Surgery XXVI (2) Dec 2011

Foot and Ankle injuries in Cricket : A Review

Overuse and stress are a common concern in modern

sports. Although stress fractures of foot have been
reported in cricket players [13], no large series of
data are currently available to comment on their true
incidence of this problem. Mansingh[14] reported on
posterior ankle impingement due to large ostrigonum
in 5 out of 6 fast bowlers from West Indies; 4 of
these required surgical excision for relief of
symptoms. The author suggested excision as the
optimal treatment for high demand bowlers who
presented with this lesion caused by excessive stress
at the back of the ankle.This lead to many theories
being put forth as to the causative factors, and
multiple issues were discussed to identify measures
that could reduce the stress behind the ankle in these
high demand cricketers. In a study by Dennis et al
[15], bowlers with an ankle dorsiflexion lunge of
12.114.0 cm on the leg contralateral to the bowling
arm were at a significantly increased risk of injury
(OR 4.03, 95% CI 1.07 to 15.21),compared to bowlers
with a lunge of >14 cm; they stated that further
biomechanical research was required before an
intervention strategy could be suggested.

malunion.An 18 year old fast bowler presentedwith

complaints of pain inthe sole of his right foot at the
neckof the first metatarsal for the pastone year. He
was asymptomatic atrest, and the pain was triggered
byhis run-up for bowling. On examinationthere was
tenderness localizedto the lateral aspect of the neckof
the first metatarsal. Radiographsrevealed a stress
fracture of thefibular sesamoid which had
subsequentlymalunited.

Fig.-2 : Showing the longstride length of some bowlers, which leads

to excessive compression posteriorly

The authors have seen a reported an unusual case of

stress fracture of the fibular sesmoidbone beneath
the great toe of a fast bowler that presented with a

Fig.-3 : Xray and CT scan showing fracture of fibular sesmoid.

The player received a local infiltration of 2%

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J of Foot and Ankle Surgery XXVI (2) Dec 2011

Foot and Ankle injuries in Cricket : A Review

Xylocaine which relieved him of his pain. In addition

shoe-wear modification by addition of a moulded
silicon metatarsal pad has helped to maintain pain
relief.

a well-fitting heel area, which can prevent sliding of

foot inside the shoe.
Two studies from Australia also looked at the
cricket ground itself as being a contributor to foot
and ankle injuries. Twomey et al [19] assessed ground
hardness as a risk factor causing injuries.Overall, 31/
38 (82%) ground assessments were rated as having
unacceptably high hardness and all others as high/
normal hardness. However, they stressed the need
for future large scale studies to confirm this as a risk
factor. Swan et al [20] stated that sports governing
bodies had more direct involvement in assessing
grounds used for higher level of play, than grounds
used for community or junior sport. There was a
general presumption that identified hazards on
community grounds would be corrected by local
councils or clubs before anyone played on them, but
this was rarely monitored. Therefore, sports governing
bodies ran the risk of being negligent in their duty of
care to sports participants if they did not formally
monitor the implementation of their ground safety
polices and guidelines. Swan et al further stated that
there was also further scope for sports bodies to work
closely with insurers to develop ground safety
assessment guidelines.

Unfortunately the pain persisted, and the player

ultimately gave up Cricket, as he did not want further
treatment. This lead to complete relief from pain at
follow up. (Prabhakar et al, case presented at 4th
World Congress of Science and Medicine in Cricket,
2011, India)

Role of Footwear and Ground hardness

Several recent reports have tried to look for effect of
different types and modifications of footwear for
bowlers.McAlpine and Kersting have reported some
benefit of increasing midsole flexibility in a cricket
bowling shoe on plantar loading and player
perception[16]. Shorter et al reported the benefits of
heel raise in pace bowlers who bowl with an extended
knee (>170) at front foot impact [17]. Bishop et al
investigated the biomechanical changes brought upon
by custom modification of shoes and reported increase
lateral shear force andknee external rotation moment
at the front leg [18]. All reports on possible role of
shoes in altering biomechanics and in prevention or
causation of injuries have been short reports so far.
Thus, this area of research on footwear remains
largely unexplored and perhaps is an area where more
future research should be foccussed.

Conclusion
From the review of the available literature, it is
evident that despite being such a popular sport, foot
and ankle injuries are not well documented in the
available literature. They are fairly common in the
professional sport, and might be even commoner in
recreational game, where appropriate documentation
is not available. There is significant paucity of data
available to help plan intervention or prevention
strategies. One cannot overemphasize the need for
continued and vigilant injury surveillance in such a
scenario and endeavors for research in the field of
footwear design.

Toenail injury or runners toe or tennis toe is

another problem that plagues cricketers, especially
fast bowlers. This occurs due to repeated impact of
the toenail (generally the first toe) against the shoebox
resulting from slight sliding of foot inside the shoe
at front foot impact during bowling. Bowlers
generally compensate for this by cutting out an area
of shoebox to accommodate for the first toe although
the overall impact of such shoe modification on
delivery stride has not been studied scientifically.
Another way of preventing this problem is to provide

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J of Foot and Ankle Surgery XXVI (2) Dec 2011

Foot and Ankle injuries in Cricket : A Review

12. Orchard J, Finch C. Australia needs to follow New

Zealands lead on sports injuries. Med J Aust
2002;177:38-9.

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