Injury Risk in Elite Basketball Players

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 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 basketball 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 particular pattern of muscle, ligament and tendon injury (see on) and the physical contact can lead to bruises, dislocations, fractures another 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 touts own problems. One huge study by Ruhr M Kuala 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 Ruhr M Kuala 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 its 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 39,541person years of basketball experience and 3,472 specific injuries. It’s 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 thunder 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 unraced, 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 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 than dental) 7.6
Foot + ankle 18.5
Lower limb (other) 3.8
Fingers Palm + wrist 57.0
Upper limb (other) 4.2
Other (nondental) 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 beat least reduced in both frequency and severity. This will be discussed in detail later. Knee strains and sprains are the next most frequent at12.4%. 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 meniscal 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’s 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 Home 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 arthritis 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 waste 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 topspin 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 sagittal 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 meniscal damage has not been shown to reduce the incidence of arthritis. 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 views supported in a paper by Carafe (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 neuron-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 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 tithe 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 ankles 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 squeal. 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. Its 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 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 Kujalaet al. (1994) (1) with 5.0% of all basketball injuries being dental. Airport by Randall (2005) (21)
discusses the impact of dental injuries and suggests that sports field 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 sports field (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. McKean (24) and Johnston et al. (25) review the arguments in 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 Kuala, (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 “Centres 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 Kuala 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 Chula (1994) (26) which discusses inconsiderable 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 Guttmann, 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 ortetraplegic had not fully exploited in their pre-injury state togetherwith the obvious cardiovascular benefits that could be obtained, but healso pointed to the psychological benefits to be gained by socialisingand competing against others.

The Disabled Person’s Employment Act (1944) was the first majorlegislative landmark in the effective rehabilitation of the disabledperson back into society and other legislation relating todiscrimination generally has helped the disabled person to achievelevels of attainment in sport that would have been unthinkable half acentury ago.

The comments that have been made in this piece in relation toable-bodied people obviously apply, in general terms, to the disabledperson as well. Clearly it depends on the nature of the disability asto what specific measures need to be employed specifically, but thebasic principles are the same. Muscle groups need to be developed inorder to protect the joints that they work over. This is particularlyrelevant to the knee.

Appropriate proprioceptive skills need to beenhanced if the risk of injury is to be kept to an acceptable minimum.More specific considerations that may involve the occupationaltherapist as well as the physiotherapist may include the prevention ofpressure problems from a wheelchair or calliper or the use ofrestraints in a patient who has sudden muscular spasms, so that theyare not thrown out of the wheelchair.

The experienced physiotherapist will be well aware of the benefitsof sport in the disabled in improving strength, co-ordination andendurance. Basketball, in particular, is commonly employed in thewheelchair-bound patient, who has to learn transferable skills in orderto propel the wheel chair accurately as well as catch, intercept andpass 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 andorganisation on the court and field of play. Such issues are of vitalimportance to the athletes although they may not either realise orappreciate 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 thecourse of action needed if an injury is sustained (viz. are theresplints, bandages, sterile water and gloves etc. available?) but equally it can be considered as the correct training and preparation ofboth the players and the game officials, so that the game itself can beplayed in conditions of optimum safety. Although the first of these two considerations is clearly important, in the context of this piece, weshall consider the second element in detail.

Prophylaxis of injury is a major concern. We have discussed thepredictive value of a pre-existing injury. It follows that, if thatinjury can be prevented, then the subject is statistically less likelyto suffer a further injury.

Common sense is behind the definitive recommendation in the paperby Kuala et al., (1) where he states that, in an attempt to reduce the incidence of injuries in basketball, specific preventative measuresshould be employed to reduce the number of violent contacts betweenplayers. He cites improving the drafting of game rules so that violentinfringements of the rules can be mo