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The elite basketball player is considered in this piece not only in terms of his potential for injury but also in terms of the potential of the physiotherapist and other sports professionals, to give advice, support and guidance so that he may practice his chosen sport as safely as is reasonably possible.
We have looked at the nature, incidence and sites of injuries
sustained. We have looked at the two most commonly injured sites (the
knee and ankle) in specific detail. We have also discussed the relevant
modalities of treatment that a physiotherapist can provide for their
clients.
There appears to be considerable controversy in the current literature,
particularly in the field of pre-exercise stretching. As this is a
commonly accepted practice by participants, coaches, trainers and
sports medicine professionals alike, we have reviewed the arguments
both for and against in some detail. We have paid particular attention
to its value in the prophylaxis of injury and the evidence to support
it.
The role of the physiotherapist in education and training of the
elite athlete is also discussed. There are a number of sources quoted
who regard it as a prime responsibility of the physiotherapist to give
the athlete the information to allow them to train and participate as
safely and effectively as possible.
We have also considered the role of the physiotherapist in the
prophylaxis of injury by looking at the various modalities of treatment
and intervention that can be employed to make the field of play a safer
place.
In addition to the main-stream elite basket ball player we have also
looked at the role of the physiotherapist in the role of helping the
disabled basketball player, some of whom have achieved elite status in
their own right. They have their own specific problems and these are
reviewed and discussed.
Lastly we look at the specific gender differences in the sport.
With many women finding that the sport is attractive, they participate
at a top level of achievement. We look at the reasons why they have a
different injury profile to men, both in terms of numbers of injuries
but also in terms of the frequency of specific types of injury. The
mechanisms of this difference is discussed together with the means
whereby it can be addressed.
Introduction
Basketball is a world-wide sport practised by children in their
backyard, adolescents in their playground, amateurs in their league
games and elite athletes in their world-stage arenas. It is – by any
standards – a fast game with inevitable physical contact, both
intentional and accidental. Both these factors lead to the potential
for injury. The explosive effort for the fast moves leads to a
particular pattern of muscle, ligament and tendon injury (see on) and
the physical contact can lead to bruises, dislocations, fractures and
other injuries. It is a sport that is enjoyed by both sexes. Although
it was originally conceived primarily as a male sport (for the YMCA)
in an era when female participation in sport was a rarity, women now
participate in it to elite levels and suffer injury to a similar extent
to their male counterparts.
The game itself has evolved dramatically since its humble
beginnings when Dr James Naismith nailed two peach baskets at the ends
of his gymnasium in 1891 (hence the name basketball) It was developed
as a tool for fitness training by the YMCA. By 1927 The Harlem
Globetrotters had been formed and by 1936 it was included as an Olympic
sport. According to FIBA (Basketball governing body) over 400 million
people play basketball on a world-wide basis
Training for the fitness needed to play the sport can also lead to
its own problems. One huge study by Urho M Kujala et al. (1994) (1)
found that of all the injuries associated with basketball, 50% occurred
during the matches and 50% occurred during training for the matches.
This should be contrasted with the finding in study by Meeuwisse et al.
(2) where injuries during the game were 3.7 times as likely to occur as
in training. One could reasonably conclude that a large proportion of
the injuries sustained in the “cut and thrust” of a full scale match
are part of the risk package accepted in playing the game. The huge
proportion of injuries sustained whilst training, however, should be
largely preventable, as training should be ideally undertaken in
carefully controlled circumstances. The physiotherapist, personal
trainer and sports medicine specialist are ideally placed to advise and
oversee poor practice in the training arena and to give advice and
guidance to maximise training efficiency and to reduce the toll of
injury.
Any experienced sports care professional will tell you that the single
most important factor in determining the likelihood of sustaining an
injury is the occurrence of a previous injury (2). It therefore follows
that prevention of any injury will help, not only in improving the
immediate efficiency of the player, but will also confer protection
against the possibility of recurring injury in any given site.
Before we consider the mechanisms and prophylaxis of injuries in
basketball, it would be prudent to consider the observed injuries from
the sport, both in absolute number and site. The study by Meeuwisse
(2003) (2) followed a cohort of 142 basketball players over a two year
period and discovered that 44.7% of the players were injured in that
time frame. As they recorded over 200 injuries in that time, it is
clear that many players were injured more than once.
The study by Urho M Kujala et al. (1994) (1) will be extensively
quoted in this piece as it provides an enormous amount of meticulously
collected data which has a high degree of confidence in it’s validity.
It was based in Finland where the population has a particularly
regimented system of bureaucratic personal information storage,
especially with regard to injury and healthcare details. The entire
population has to be registered with a nationally based health
insurance, which records every accident and injury. This is of enormous
value to studies such as this, as accurate statistics about entities
such as specific sporting injuries can be derived comparatively easily.
The study is also important in this specific regard as it
encompasses an enormous cohort of basketball players analysing 39,541
person years of basketball experience and 3,472 specific injuries. It
is worth considering the patterns of injury found in some detail as it
has an impact on the deliberations in this piece.
In terms of age distribution, it was found that injuries in the
under 15 yr. age group were comparatively rare and that the injury rate
peaked in the 20 – 24 yr. age groups.
Percentage of injuries by sites in basketball players
(These results are slightly modified with some trivia removed)
Injury Site % of total
Lower limb Total 56.0
Thigh 2.5
Knee 15.8
Leg 2.0
Ankle 31.4
Foot 4.0
Other 0.4
Upper Limb total 19.3
Upper arm + Shoulder 2.6
Forearm and elbow 1.3
Palm + wrist Fingers 11.1
Other 0.4
Other Sites Total 24.7
Teeth 5.2
Eyes 3.0
Head + neck 7.4
Thorax + Abdomen 1.5
Back 5.4
Pelvis 0.9
Multiple sites 1.4
There are clearly a number of striking trends in these figures. The
lower limbs sustaining the most injuries with 56% of the total. The
ankle and knee taking the lion’s share of these. These results are
clearly fairly predictable with the nature of the sport being one of
sudden changes of acceleration and direction, many changes of direction
(pivoting) involving turning forces impinging maximally on the knee and
ankle. Both joints are intrinsically unstable for these modalities of
movements. They are designed to be most effective in walking and
running in a straight line. Although they can accommodate twisting
movements, they are much less mechanically sound in these directions.
The possibility of unanticipated, and therefore unbraced, impacts is
endemic in the sport and will increase the possibility of injury to
these joins in particular.
The upper limb has a substantial tally of injuries with the bulk
being to the palm, wrist and fingers. Although it is not specified in
this particular study, any experienced clinician would expect to see a
substantial proportion of hyperextensions and dislocations to the
fingers and sprains and strains to the wrist (this is partially
amplified in the next section).
For a sport that involves considerable manipulative and throwing
skills, it is, perhaps, surprising that the shoulder and upper arm
account for only 2.6% of all the injuries. In contrast to the comments
made about the knee and ankle, one can postulate that the shoulder, by
virtue of its design to accommodate a much greater range and compass of
movement, is less likely to be injured in the way that the knee and
ankle are. Also, in the course of the normal game, it is subject to
rather less overall mechanical force as both the knee and ankle have to
assimilate peak loads of several times the body weight whereas the
shoulder, unless involved in a fall, does not.
Of the “Other Sites”, the neck and back are the commonest sites for
injury. To a large extent, this again is a reflection of the explosive
nature of the game with frequent changes of direction and velocity with
high levels of acceleration.
Having recognised the major sites of injury it is now prudent to discuss the main types of injury.
Percentage injury by type in basketball players
(These results are slightly modified with some trivia removed)
Injury type + site % of total
Sprains +strains 61.3
Knee 12.4
Ankle 29.5
Bruises + Wounds 22.2
Fractures 12.6
Fracture (other then dental) 7.6
Foot + ankle 18.5
Lower limb (other) 3.8
Fingers Palm + wrist 57.0
Upper limb (other) 4.2
Other (non dental) 16.6
Dental 4.9
Dislocations 1.7
Knee 0.5
Shoulder + elbow 0.3
Fingers 0.3
Others 2.2
Sprains and strains are the commonest type of injury in this sport
with the ankle being the most frequently injured site in this respect.
Considerable amounts of work and research have been done
(2,3,4,5,6,7,8) to try to find mechanisms whereby ankle injuries can be
at least reduced in both frequency and severity. This will be discussed
in detail later. Knee strains and sprains are the next most frequent at
12.4%. Similar amounts of work have been done to find ways of
minimising knee injuries (9,10,11). The knee injury is notorious for
producing long-term debilitating problems as not only is the acute
injury painful and potentially debilitating in itself, but there is
also the potential for Anterior Cruciate Ligament (ACL) damage and
meniscial damage and wear as well. This may not be immediately apparent
but may contribute to morbidity at a later date. This study (1) found
that knee injuries were the most common cause of permanent disability
In the longer term. During the time frame of this study, four
basketball players sustained permanent injuries.
In specific relation to knee and ankle injury, the Meiuwess study
(2) found that the situation can be further amplified by the finding
that the greatest number of injuries which resulted in seven or more
sessions being lost in a season arose from the knee. Equally striking
was the fact that the most common injury that involved less than seven
sessions being lost, were injuries to the ankle. This underlines the
comment made earlier that knee injuries tend to be potentially more
serious than ankle injuries
Bruises and wounds account for over 1/5th of the total types of
injury and fractures account for just over 1/10th. In line with the
comments made earlier about the frequency of hand, finger and wrist
injury, it will come as no surprise therefore to see that the hand and
wrist accounts for over half of the total of fractures. The foot and
ankle account for 18.5% of total fractures. This is a reversal of the
figures relating to site of injury. It would therefore appear that the
hand gets injured less frequently that the foot, but when it does, it
is more likely to sustain the more serious (fracture) type of injury.
Although the foot is more likely to be injured, it is more likely to
suffer a strain or sprain rather than a fracture.
In the study by Hame et al.,(2004) (12) There was an unexpected, and
slightly worrying, conclusion. They found that, in a study of fractures
in sport, that (for men at least) basketball was the sport that put the
participants at greatest risk of sustaining a fracture.
The Knee and Basketball
As we have already discussed, a knee injury is potentially more
serious than just the implication of the immediate acute injury. For
that reason, and for the fact that it is one of the two most commonly
injured areas, we will look at the knee as a specific entity.
We know that the single most important predictor for further
injury is the past history of a preceding original injury. The knee is
also significant insofar as the normal maxim of rest a joint until the
inflammation has settled is rarely practical, as the knee is essential
for locomotion and, as any experienced clinician knows, the vast
majority of patients with resolving knee injuries will wait until the
pain subsides to a tolerable level, and then start to walk on it. This
effectively means that the joint is being stressed while resolving
inflammation is present. Initially this may manifest itself as no more
than a mildly aching knee, but it is likely that menisci, cruciate
ligaments and articular surfaces are all being stressed in a “less than
optimal” state.
It is likely, on a first principles basis, that this type of
mechanism may be, in part at least, responsible for the increased
levels of arthrosis and arthritis that is observed in lifelong
athletes. (13,14)
The paper by Meeuwisse (2) has been quoted several times in this
piece. It is worth remembering that his team found that the knee was
the joint which, if injured, gave rise to the longest periods of
incapacity. It is therefore prudent to consider the mechanisms of
injury, the treatment of those injuries and, possibly more importantly
in the context of this piece, what can be done to minimise the
incidence and impact of those injuries.
We would commend an excellent paper by Bahr (2001) (3) on the
subject. He discusses (amongst other things) the current thinking on
knee injuries. He makes comment on the increasing incidence of cruciate
ligament injuries. These injuries are seen with greatest frequency in
athletes who participate in sports that involve “pivoting” – a movement
which involves a fixed foot on the floor being used as a fulcrum to
spin the body around – a movement which can put huge rotational
stresses on the knee joint. As has been observed earlier in this piece,
the knee is designed primarily to be efficient in dealing with
movement in a saggital plane. It is very poorly adapted to deal with
rotational stresses.
Bahr observes that the maximal incidence of cruciate ligament
injury is in the 15-25 yr. old age group and in women three to five
times more frequently than in men (see on) (14). He also refers to the
post-injury, long-term complications of abnormal joint mechanics and
the early onset of degenerative joint disease (15). Significantly he
points to the fact that, although there has been an increasing trend
recently (mainly because of improved operating techniques) to attempt
to repair menisci and cruciate ligaments, this has not been accompanied
by an apparent reduction in the rate of post-traumatic osteoarthritis.
Similarly, arthroscopic repair of isolated meniscial damage has not
been shown to reduce the incidence of arthrosis. These factors all
mitigate the argument that, although treatment is important, the
identification of risk factors that predispose to injury is even more
important.
The Anterior Cruciate Ligament (ACL) is commonly injured in
circumstances that many athletes would consider as normal or routine
for their particular sport. Frequently the damage occurs without direct
physical contact to the knee (9). This is strong evidence to support
the “design fault” explanation of the aetiology. There is recent
anecdotal data to suggest that improving the control of the knee may
have an impact in reducing the incidence of these injuries. This view
is supported in a paper by Caraffa (10) who looked at improving the
proprioceptive and balance mechanisms in footballers over a three
season period. They reported an 87% decrease in the incidence of
injuries to the ACL. It may be significant that they studied
semi-professional and amateur footballers who, presumably, did not
train as efficiently of as skilfully as their professional footballer
counterparts and therefore there was probably considerable room for
improvement.
Similarly constructed studies have shown similar pattern of improvement
in young female football (11) and handball (16) players using a similar
programme of training over a season. As has been pointed out earlier,
such changes are more likely to be noticeable in females because of the
higher incidence of ACL injury in the first place. Bahr points out that
these studies were too small to allow a proper statistical evaluation
of the reduction of injury to the ACL specifically, but there is
sufficient evidence to conclude that the risk of serious knee injury
can be significantly reduced by the introduction of structured training
exercises that focus on improving the neuro-muscular control of the
knee.
Bahr makes the very salient point that balance (proprioceptive)
training is not yet universally recognised by coaches and trainers as a
useful tool. As a result, he argues that it is the responsibility of
doctors and physiotherapists to disseminate the knowledge that such
training does reduce the incidence of serious short-term (and therefore
long-term) knee injury.
Anterior knee pain is a common, sometimes chronic presenting
symptom in any sports related health professional’s clinic. There are
many theories as to its aetiology and it is notoriously resistant to
treatment. An unattributed paper (quoted by Minerva in the BMJ) (17)
refers to Jumper’s knee where the pain is maximal near the attachment
of the patella ligament. Ultrasound of the region can show an area of
increased echogenicity in the inferior pole of the patella. Minerva
quotes the study as observing that of 100 athletes seen in one clinic,
18 had to give up their sport for over a year and about 1/3rd needed
surgery in order to try to get resolution of the problem.
In conclusion to this section we would refer the reader to the
excellent paper by Adams WB (2004) (18) who reviews the current
thinking on treatment options on both overuse syndromes and trauma to
the knee.
The Ankle and Basketball
As we have seen earlier, the ankle is the single most commonly
injured site in the body during basketball comprising 31.4% of all the
injuries observed (1) and ankle strains and sprains were the single
commonest mechanism of injury observed with 1/3rd of all such injuries
and 1/5th of all fractures. We will therefore also consider the ankle
as a special case.
Bahr (3) quotes that in round figures 20% of sports related injuries
involve the ankle. The vast majority of ankle injuries are simple
sprains of the lateral and medial ankle ligaments. Proper functional
care will allow the patient to return to work within a few days, or at
worst a few weeks, with minimal sequelae. Some sprains are found to
cause prolonged disability in the form of chronic instability or
persistent pain.
Prophylaxis of injury is discussed elsewhere in this piece but it
should be noted that taping and bracing are commonly employed
techniques for protection, but their efficacy has only been
demonstrated in sportsmen with a history of previous injury (5,6).
There is little doubt that taping and bracing will reduce the incidence
of sprains and result in less severe strains. “High-top” basketball
boots have been introduced recently on the assumption that similar
boots (18a) (viz. ski boots) reduce the incidence of ankle injury, but
it has not yet produced any specific evidence that sprains and strains
are reduced.
Braces seen to be more effective than tape in preventing sprains of
the ankle (7,8) Bracing has the advantage that it is more acceptable in
terms of comfort for long-term use (6). Taping is commonly used but
appears to be less effective than braces because it relies on adhesion
to the skin to exert its protective influence. It can cause skin
irritation and has to be reapplied on virtually every occasion where
potential stress can occur.
One of the major problems of doing research into ankle injuries is
that qualitative and subjective measurements such as pain and
immobility can be easily assessed, but the ankle joint is a very
functionally complex structure and quantitative measurements of
anything other than flexion/extension or rotation an very difficult. It
is therefore heartening to read of a Dutch group who are developing a
specially designed goniometer to use in researching the pathology of
the ankle joint (19). This is only mentioned for the sake of
completeness and we do not propose to go into any detail about the
instrument.
There is an excellent article by McKay on ankle injuries in
basketball (20) but this is discussed at some length in the section on
prophylaxis of injuries.
Treatment of injuries
The treatment of sports related injuries is a vast topic and a
specialism in itself. The sports medicine medical specialist and the
physiotherapist sports specialist are technically knowledgeable people
who have had to assimilate a vast quantity of information relative to
their specialisation. It is therefore not proposed to present the topic
in any great detail but to cover the elements of treatment of acute
injuries and their subsequent treatment that are specifically important
to the field of basketball. We will also present a brief literature
review of some of the most recent papers in the field.
In general terms, the old adage of ICE (immobilisation, compression
and elevation) (20b) is a useful first-aid mnemonic which will help to
minimise injury prior to assessment by a more specialist professional.
In this article it is proposed to look primarily at the aspects of
treatment which impinge on the areas covered in this piece and broad
overviews. We shall restrict ourselves here to a brief literature
review of some of the most important recent papers
The area of dental trauma is highlighted in the analysis by Kujala
et al. (1994) (1) with 5.0% of all basketball injuries being dental. A
report by Ranalli (2005) (21)
discusses the impact of dental injuries and suggests that sportsfield
medical personnel should have at least basic training in the first-aid
of dental injuries so that they can, at least, provide appropriate care
until a dental specialist can be properly involved.
A particularly controversial issue is raised by Dietzel and Hedlund
(2005) (22) They review the current controversy about the use of
analgesic and anti-inflammatory injections both in the acute phase of
injury (to allow continued participation in a sporting event) or in the
chronic recovery phase. This is a particularly well balanced article
which evaluates both sides of the arguments for and against the use of
injectable medications.
Sanchez et al.(2005) (23) review the desperately important area of
management of the potentially spine-injured athlete. This is an area
which has had substantial changes in management techniques in the
recent past. This paper is a particularly useful review of techniques
of diagnosis and stabilisation of the injured athlete. Very
significantly it highlights the role of pre-injury planning – so often
overlooked – on the sports field.
There are two recent papers which examine the thorny problem of
concussion on the sportsfield (24,25). This has long posed a problem
for the supervising healthcare specialist, both in terms of immediate
diagnosis and subsequent action and treatment. The working “rule of
thumb” has been that any player with definite signs of concussion
(impaired consciousness or increased level of confusion) should be
taken off the field and not returned to play for 48 hrs. In practice,
this advice may be ignored by coaches who are anxious to keep their
best players on the field and who may be ignorant of the potential side
effects. McKeag (24) and Johnston et al. (25) review the arguments in a
coherent manner and present the current thinking in a modern context.
Injury types in relation to position played
There are few studies that actually compare the rates and types of
injury with actual position played on the court. Given the fact that
Kujala, (1) reports that 50% of injuries are sustained in training
rather than on the court, this may prove to be rather academic.
The study by Meeuwisse (2003) (2), was one of the few that looked at
this issue and regarded it as purely peripheral to the main mechanism
of injury. However , they summed up the findings of the study in the
phrase “Centers had the highest rate of injury, followed by guards, and
then forwards. The relative risk of re-injury was significantly
increased by previous injuries to the elbow, shoulder, knee, hand,
lower spine or pelvis, and by concussions.” As part of their
conclusions the research team commented that the predictive risk
factors for injury were, in order of importance: - previous injury,
number of games played, the number of player contacts during a game,
player position, and court location (this is a reference to the
proximity to a hospital). In real terms, the players position is of
much less importance in predicting injury than many other factors
Clinical considerations
The clinical implications of basketball injury must be viewed in
the context of the benefits derived from playing any competitive sport
– or indeed pursuing any degree of fitness. Virtually any sporting
endeavour has a downside and indeed risks associated with it, but
equally there are very considerable benefits to be gained as well. By
concentrating (by necessity) on the risks of injury in basketball in
this article we do not wish to ignore the balancing perspective of the
health gains to also be derived.
Clearly, one of the major benefits to be gained is the concurrent
increase in cardiovascular fitness (13) This is in addition to the less
easily quantifiable benefits of general fitness, social interaction,
increase in self-confidence and satisfaction in participation which are
common to most sporting endeavours.
The study by Kujala et al. (1993) (13) looked at the incidence of
degenerative joint conditions in elite athletes. It found that
participation in sports generally could lead to premature
osteoarthritis. Specifically it found that, in the elite international
athletes studied there was a greater than predicted admission rate to
hospital for treatments for osteoarthritis of the hip, knee and ankle.
Very significantly, in the context of this article on physiotherapy, it
concluded that proper treatment of injuries to these joints could
significantly reduce the incidence of premature osteoarthritis in this
group. It should be noted that this was a large control moderated study
of over 2000 international athletes so the findings are clearly
significant
Disability and basketball
It is important not to ignore the fact that basketball is played,
not only by able-bodied sportsmen but also by those who have a
concurrent disability as well. This group also presents a professional
problem for the physiotherapist as. Not only are there the “normal”
considerations for the able-bodied player that we have discussed in
this piece, but also there may well be disability-specific
considerations in the disabled player which will tax the
physiotherapist every bit as much as those in their able-bodied
counterparts. In consideration of this we would commend the reader to
an excellent article by Chawla (1994) (26) which discusses in
considerable depth, the whole issue of sports specific medical
considerations for people with a disability.
The use of sports for the disabled as a therapeutic measure was
championed by Sir Ludwig Guttman, who was a specialist in spinal
injuries. He pointed out not only the obvious physical benefits to be
gained in improving functions of the body which the paraplegic or
tetraplegic had not fully exploited in their pre-injury state together
with the obvious cardiovascular benefits that could be obtained, but he
also pointed to the psychological benefits to be gained by socialising
and competing against others.
The Disabled Person’s Employment Act (1944) was the first major
legislative landmark in the effective rehabilitation of the disabled
person back into society and other legislation relating to
discrimination generally has helped the disabled person to achieve
levels of attainment in sport that would have been unthinkable half a
century ago.
The comments that have been made in this piece in relation to
able-bodied people obviously apply, in general terms, to the disabled
person as well. Clearly it depends on the nature of the disability as
to what specific measures need to be employed specifically, but the
basic principles are the same. Muscle groups need to be developed in
order to protect the joints that they work over. This is particularly
relevant to the knee. Appropriate proprioceptive skills need to be
enhanced if the risk of injury is to be kept to an acceptable minimum.
More specific considerations that may involve the occupational
therapist as well as the physiotherapist may include the prevention of
pressure problems from a wheelchair or calliper or the use of
restraints in a patient who has sudden muscular spasms, so that they
are not thrown out of the wheelchair.
The experienced physiotherapist will be well aware of the benefits
of sport in the disabled in improving strength, co-ordination and
endurance. Basketball, in particular, is commonly employed in the
wheelchair-bound patient, who has to learn transferable skills in order
to propel the wheel chair accurately as well as catch, intercept and
pass the ball.
Prophylaxis and pre-injury actions
Earlier in this piece we briefly discussed a paper by Sanchez (23).
and commended it for its tackling of the problem of anticipating an
injury. This involved a significant amount of pre-planning and
organisation on the court and field of play. Such issues are of vital
importance to the athletes although they may not either realise or
appreciate it at the time. This type of forward thinking can lead to
dramatic reductions in morbidity (or even in mortality) and should be
the concern of each and every healthcare professional who is working in
the field of acute sports injury.
Prophylaxis can be considered not only as actual pre-planning the
course of action needed if an injury is sustained (viz. are there
splints, bandages, sterile water and gloves etc. available?) but
equally it can be considered as the correct training and preparation of
both the players and the game officials, so that the game itself can be
played in conditions of optimum safety. Although the first of these two
considerations is clearly important, in the context of this piece, we
shall consider the second element in detail.
Prophylaxis of injury is a major concern. We have discussed the
predictive value of a pre-existing injury. It follows that, if that
injury can be prevented, then the subject is statistically less likely
to suffer a further injury.
Common sense is behind the definitive recommendation in the paper
by Kujala et al., (1) where he states that, in an attempt to reduce the
incidence of injuries in basketball, specific preventative measures
should be employed to reduce the number of violent contacts between
players. He cites improving the drafting of game rules so that violent
infringements of the rules can be more severely dealt with and that
these rules should be supported with more diligent refereeing.
In view of the number of dental injuries recorded in the game of
basketball, Kujala et al. also recommend the mandatory wearing of
dental shields or mouthguards
It should be noted that taping and bracing are commonly employed
techniques for protection in many sports, but their efficacy has only
been demonstrated in sportsmen with a history of previous injury (5,6).
These techniques are most frequently applied to the ankle and knee
joints as these joints are both the most commonly affected and also
they move in a primarily saggital plane, therefore they are technically
the easiest to mechanically brace.
Other joints can be braced. The elbow can be successfully supported. It
is a common sight in players of racket sports to see a brace in place.
Clearly this is of use if there is joint instability, but it is often
mistakenly used in cased of “tennis elbow” where its value is often
little more than a placebo.
There is little doubt that taping and bracing will reduce the
incidence of sprains and result in less severe strains. The
introduction of “high-top” basket ball boots has not produced any
definitive evidence that sprains and strains are reduced.
Braces seen to be more effective than tape in preventing sprains of
the ankle (7,8) Bracing seems to be more acceptable in terms of comfort
for long-term use. Taping is clearly cheaper but will probably have to
be re-applied at every sporting occasion.
We do not propose to discuss taping in detail as there are a great
many different techniques invented by a great many different
clinicians, all of whom will, no doubt, claim that there particular
method is the best. We do not presume to make a judgement on this issue
and when referring to “taping” this should be taken as a generic
process rather than a specific one. In most cases the object of the
exercise is to reduce the range of abnormal movement at a joint and
also (on occasions) to reduce the possible movement in a normal
direction, in an attempt to help to reduce the inflammatory processes
that may be present. In most cases, the taping can be applied by the
patient themselves after basic instruction by the doctor or
physiotherapist.
There is the commonly held belief that strapping or braces should
not be worn because they impair performance. In a study by Thacker et
al., (1999) (27) a careful study of the literature was made and they
were able to conclude that “appropriately applied braces, tape, or
orthoses do not adversely affect performance.” They were also able to
recommend that, after an ankle injury, athletes should complete a
supervised rehabilitation before returning to practice or competition
and those athletes who suffered moderate or severe sprain should wear
an appropriate orthosis for at least six months.
In a theme that we shall return to in this piece, Thacker concludes by
observing that it is not only doctors and physiotherapists that must
assume the burden of responsibility for prevention of injuries in
sports, but it is also the coaches, trainers and, indeed, the athletes
themselves, who must also share in that responsibility.
Pre-match training is a major area where athletes and their
professional advisors can influence both the incidence and severity of
injuries. Appropriate strength, agility and flexibility training will
all help to reduce the likelihood of problems arising during and after
play.
Stretching is an area of considerable controversy at present. Most
authorities would agree that a pre-match warm-up and stretch is a good
sensible prophylactic measure. Hard evidence for this (in terms of
randomised, placebo controlled trials) is hard to find. The second
edition of McAtee and Charland’s book (28) Facilitated stretching, is a
useful compendium of opinion on the subject. It has been well reviewed
by a physiotherapist, Ian Horsley, (29) who makes some very pertinent
observations on the text. Controversially, the book expounds the
virtues of post-match stretching rather than pre-match stretching. It
is particularly useful for an erudite explanation of the current
thinking on the anatomy and physiology of the stretch reflex and the
impact of this on the various modalities of stretching techniques.
In terms of research specifically into the role of stretching in
the prophylaxis of injury, an interesting review of the available
literature is provided by Yeung (30) who examined the available
literature and came to the conclusion that “Stretching is perhaps the
most common routine advocated by sports coaches and sports medicine
professionals. In this study, no evidence for its effectiveness in the
prevention of sport related injury was found. “ It is fair to observe,
however, that the implication that stretching does not reduce
subsequent injury is not justified. Yeung qualifies his statement by
asserting that the reason that “no evidence could be found” was due to
the fact that the trials studied were not sufficiently scientifically
rigorous to provide unequivocal evidence of the benefits of stretching.
He cites studies (31,32,33) as examples of this.
Ian Shrier (2000) produces a very thought provoking article (34) in
which he specifically looks for the evidence to support the perceived
role of stretching in reducing injuries. He points to the fact that
many of the trials that came out in support of stretching used
stretching as a co-intervention and therefore the effects of stretching
could not be isolated. In one, often quoted study, Ekstrand et al.
(1983) (35) reported a 75% reduction in injury rates after using
stretching as a warm-up routine. Careful reading shows that while this
is true, Ekstrand’s study also used leg guards, special shoes, taping
ankles, controlled rehabilitation, education, and close supervision
during play, so it was hardly surprising that there was a significant
reduction in injury rates.
In his pursuit of an answer, Shrier produces some carefully constructed
arguments regarding stretching. Most injuries occur during eccentric
muscle contractions (36) which has the ability to cause damage inside
of the normal envelope of motion because of the differing length of the
muscle sarcomeres (37). Why then, if injuries occur within the normal
range of movement, would an increased range of movement prevent
injuries? It is a physiological fact that even mild stretching can
cause a degree of damage at the cellular level (38). It also appears
that stretching has an ability to produce a tolerance to pain or an
analgesic effect (39,40,41). Why, he argues, should it be considered
prudent to increase the tolerance to pain, produce some damage at the
cellular level and then exercise this damaged, partially anaesthetised
muscle? Against this he cites the counter argument that there is
scientific data to support the warm up as a prophylactic for injuries
during a match (42)
Other risk factors can be identified that can predispose to injury.
Overzealous or misguided training schedules can also lead to overuse
syndromes in their own right. In addition to strength training, elite
basketball players will often run considerable distances on a weekly
basis in order to improve or maintain their levels of cardiovascular
fitness. This can have associated problems and the supervising
physiotherapist should be aware of the potential hazards. liotibial
band syndrome, tibial stress syndrome, patello-femoral pain syndrome,
Achilles tendinitis, and plantar fasciitis have all been associated
with overtraining (30). Prophylaxis can be achieved by modifying the
training schedule, adequate warm-up and stretching and possibly
modifying the footwear.
There is evidence to suggest that athletes who train one to three days
per week are less likely to be injured than those who train five days
per week (30). Similarly, with intense training, athletes who train for
15-30 mins. per day have significantly lower injury incidence than
those who train for 45 mins a day ( The reference here is to running
training - not any other form). Interestingly, the results of this
study showed that there was no significance in the prevention of
injuries (from the running section of training) when a graduated
programme was used.
A specific and large study on the subject of ankle injuries in
basketball (20) also makes interesting reading. Significant findings
included the fact that the ankle injury rate was 3.85 per 1000
participations in a match, with almost half missing at least one week
of competition as a result of the injury. In terms of prophylaxis, the
study finds that factors that increased the risk were:
a) A history of previous ankle injury made it five times more likely to sustain a further injury.
b) b) Air cells in the heels of shoes made it 4.3 times more likely and
c) c) players who did not stretch before the game were 2.6 times more likely to injure an ankle than those who did.
The authors noted that taping a previously injured ankle reduced the
likelihood of further injury, although they could not quantify the rate
of reduction due to other concurrent factors
Male vs. Female considerations
Basketball is a sport that is enjoyed by both male and female
participants. It does not follow, however, that the injury patterns are
the same for both sexes. One can argue that men may tend to be
physically heavier, more aggressive and move faster, all of which are
indisputable anatomical and physiological facts. These reasons can be
cited as reasons why male and female injury patterns are different.
Unfortunately that is nowhere near sufficient to explain some of the
observed facts.
Some of the most studied differences come in relation to injuries
to the knee. Women damage their ACL over three times more frequently
than men. (20a)If the explanations of body weight, speed or aggression
were employed, then one would confidently predict that men were more
likely to suffer than women. Arendt (14) studied the problem and
postulated that there were possibly a great many factors that could
influence the aetiology of the injury. His team thought that it was
likely that non-contact mechanisms were the main factor in the genesis
of these injuries. They cited several different mechanisms of injury
including such extrinsic factors such as relative muscular strength,
shoe-surface interface and specific body geometry (women have a wider
stance than men due to the anatomical shape of the pelvis. They also
cited certain intrinsic factors such as cyclical joint laxity (under
the influence of the menstrual hormones), the actual dimensions of the
inter-condylar notch in the knee (where the ACL runs) and also the
actual size of the ACL itself.
As a matter of completeness we would also cite the paper by Agel et
al. (2005) (43) which also looks specifically at the issue of ACL
injury, in the broader context over a prolonged period (1990-2002).
This paper provides a very detailed analysis of the injuries sustained
while playing basketball. It enhances the arguments for an extrinsic
causation of the excess of female injuries by quoting the fact that
there was found to be no significant difference between the injury
rates of men and women after direct contact incidents. Women, however,
sustained a higher rate of non-contact injuries than men did.
Further evidence for non-contact, intrinsic causes for the ACL sex
difference is found by comparing the rates of ACL injury in basketball
with those rates in football. A similar preponderance in female injury
is found (43) implying that the difference is not likely to be sport
specific. One completely unexplained finding was the fact that, over
the 13 years that the study ran, the ACL injury rate for men
progressively fell whereas the rate for women remained constant. The
authors did not offer any explanation for this fact other than they
postulated that the message to increase proprioception enhancing
training may be being absorbed by the male population more effectively
that the female population.
Agel concludes the article with a comment that bears repeating.
Despite focusing in this section on the injury of the ACL, it should be
remembered that such injuries are still comparatively rare events when
taken in the context of the totality of the sport. The possibility of
ACL injury should not be allowed to put off participation in the sport.
Discussion
The whole issue of injury in the area of basketball is the
consideration of those issues that are relevant to sport in general and
those that are specific to basketball. In this piece we have considered
both areas. The incidence and types of injury have been discussed in
detail together with the appropriate measures that a physiotherapist
can take to minimise the incidence and severity of a specific injury
occurring.
The knee and ankle are areas at particular risk of injury and we
have discussed these as separate cases both in terms of the mechanism
of injury and the prophylaxis of the injury.
It is clear from reviewing the literature on the subject, that the
whole area of stretching before and after exercise is confused, with
reputable authorities presenting arguments both for and against the
issue. It would appear that, on balance, there is a general
ground-swell of feeling that pre-exercise stretching is useful and a
valuable prophylactic against injury however, there appears to be
little peer-reviewed literature which can be cited as unequivocal
support for this view. Most of the studies that have been done in this
area have not looked at stretching as a single entity but have included
it as part of a pre-exercise routine. As a result, there is little firm
evidence that stretching – by itself – is of unequivocal value.
It is clear, from consideration of all of the evidence, that there
is a great deal that a physiotherapist can do both in terms, not only
of treatment, but also in terms of knowledgeable advice and guidance,
to help the participants in the field of basketball compete safely.
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