Injury Risk in Elite Basketball Players

Injury Risk in elect Basketb all told PlayersThe elite basketball pseud is argueed in this piece non only in call of his potential for hurt but too in terms of the potential of the physiotherapist and other athleticss professionals, to give advice, support and guidance so that he whitethorn practice his chosen gas as safely as is reasonably possible.We devour looked at the nature, relative relative incidence and sites of injuries bear on. We deport looked at the two roughly ordinarily injure sites (the stifle joint and mortise joint) in particularised s exceed. We keep in whatever case discussed the relevant modalities of treat handst that a physiotherapist bottom provide for their clients.There appears to be extensive controversy in the current literature, particularly in the field of pre-exercise stretching. As this is commonplacely accepted practice by participants, coaches, trainers and mutations medicine professionals alike, we rich person revie wed the arguments two for and against in about detail. We drive paid particular tutelage to its value in the prophylaxis of combat daub and the evidence to support it.The role of the physiotherapist in education and home puzzle out of the elite athlete is also discussed. There be a list of sources quoted who touch it as a prime responsibility of the physiotherapist to give the athlete the watch to dispense with them to train and participate as safely and effectively as possible.We have also portion outed the role of the physiotherapist in the prophylaxis of blur by looking at the various modalities of interference and interference that finish 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 testify right. They have their own specific problems and thes e be reviewed and discussed.Lastly we look at the specific gender differences in the shimmer. With m whatsoever women conveying that the sport is attractive, they participate at a top level of achievement. We look at the reasons why they have a different wound profile to men, both(prenominal) in terms of physiques of injuries but also in terms of the frequency of specific pillow slips of flaw. The mechanisms of this difference is discussed together with the means whereby it can be addressed. mental hospitalBasketball is a world-wide sport practised by children in their backyard, adolescents in their playground, amateurs in their league crippleds and elite athletes in their world-st date arenas. It is by any standards a lush plump for with inevitable physical contact, both wise(p) and accidental consonant. Both these factors expand to the potential for flaw.The explosive effort for the fast moves leads to particular pattern of muscle, ligament and tendon imperfect ion (see on) and the physical contact can lead to bruises, dislocations, fractures some 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 elaboration in sport was a rarity, women now participate in it to elite levels and suffer injury to a similar finale to their male counterparts.The game itself has evolved dramatically since its humble beginnings when Dr pile Naismith nailed two peach baskets at the ends of his gymnasium in 1891 (hence the name basketball) It was developed as a mechanism for fitness training by the YMCA. By 1927 The Harlem Globetrotters had been organize and by 1936 it was included as an Olympic sport. According to FIBA (Basketball governing body) over 400 million multitude play basketball on a world-wide flat coatTraining for the fitness ask to play the sport can also lead touts own problems. whizz wide break down by Ruhr M Kuala et al. (1994) (1) gear up that of all the injuries associated with basketball, 50% occurred during the markes 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 time as potential to occur as in training.One could reasonably conclude that a large proportion of the injuries continue in the prove 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 care in full controlled circumstances. The physiotherapist, personal trainer and sports medicine specializer are ideally displace 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(prenominal) experienced sports care professional allow secern you that the wizard most(prenominal) 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 provide help, non only in better the immediate efficiency of the player, but testament also confer protection against the possibility of take place injury in any given site.Before we ask the mechanisms and prophylaxis of injuries in basketball, it would be prudent to consider the find 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 termination 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 than once.The study by Ruhr M Kuala et al. (1994) (1) will be extensively quoted in this piece as it provides an enormous measuring stick of meticulously colle cted data which has a high pointedness of confidence in its validity. It was based in Finland where the world 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 e rattling accident and injury. This is of enormous value to studies such as this, as accu position 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 old age of basketball experience and 3,472 specific injuries. Its worth considering the patterns of injury put 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 lofty 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 limited with some trivia removed)Injury Site % of total put down limb Total 56.0 Thigh 2.5 Knee 15.8 Leg 2.0 mortise-and-tenon joint joint 31.4 invertebrate ft 4.0 Other 0.4Upper arm total 19.3 Upper arm + Shoulder 2.6 forearm and elbow 1.3 Palm + radiocarpal joint Fingers 11.1 Other 0.4Other Sites Total 24.7 Teeth 5.2 Eyes 3.0 Head + know 7.4 Thorax + Abdomen 1.5 Back 5.4 Pelvis 0.9 nine-fold sites 1.4There are clearly a number of striking trends in these figures. The lower limbs sustaining the most injuries with 56% of the total. The mortise-and-tenon joint and knee taking the lions share of these. These results are clearly fairly predictable with the nature of the sport existence iodine(a) of emergent 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 military campaigns. They are designed to be most effective in passing gameing and running in a straight line. Although they can accommodate twisting movements, they are much little mechanically sanitary in these directions. The possibility of unanticipated, and therefore unraced, impacts is endemic in the sport and will accession the possibility of injury to these joins in particular.The upper limb has a significant tally of injuries with the bulk be 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 broadsheet for only 2.6% of all the injuries. In contrast to the commentarys made about the knee and ankle, one can postulate that the shoulder, by virtue of its design to accommodate a much greater chuck and compass of movement, is less(prenominal) likely to be injured in the way that the knee and ankle are.Also, in the course of the modal(prenominal) 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 lading whereas the shoulder, unless involved in a fall, does not.Of the Other Sites, the pick out 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 treasure the major sites of injury it is now prudent to discuss the main lawsuits of injury.Percentage injury by type in basketball players (These results are slightly modified with some trivia removed)Injury type + site % of t otalSprains +strains 61.3 Knee 12.4 Ankle 29.5Bruises + Wounds 22.2Fractures 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 4.9Dislocations 1.7 Knee 0.5 Shoulder + elbow 0.3 Fingers 0.3 Others 2.2Sprains and strains are the commonest type of injury in this sport with the ankle cosmos the most frequently injured site in this respect. Considerable amounts of work and research have been make(2,3,4,5,6,7,8) to try to find mechanisms whereby ankle injuries can beat least decreased in both frequency and severity. This will be discussed in detail after. 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 penetrative injury tortureful and potentially debilitating in itself, but there is also the potential for Anterior Cruciate Ligament (ACL) malign 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 ca give 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 wicked than ankle injuriesBruises and wounds account for over 1/5th of the total types of injury and fractures account for provided 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 regression 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, its 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 BasketballAs we have already discussed, a knee injury is potentially m ore 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 ordinarily injured champaigns, we will look at the knee as a specific entity.We know that the single most important predictor for further injury is the past tale of a preceding original injury. The knee is also significant insofar as the normal maxim of rest a joint until the inflammation has colonized is rarely practical, as the knee is essential for travel 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. ab initio this may manifest itself as no more than a mildly aching knee, but it is likely that menisci, symmetric ligaments and articular surfaces are all being stressed in a less than optimal state.It is likely, on a first gear principles basis, that this type of mechanism may be, in part at least, obligated for the increase levels of arthritis and arthritis that is observed in lifelong athletes. (13,14)The report by Meeuwisse (2) has been quoted several times in this piece. It is worth remembering that his police squad found that the knee counterbalance 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 praise an fine musical theme 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 movem ent 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 ill 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 invokes to the post-injury, long-term complications of abnormal joint mechanics and the early onset of chronic joint distemper (15).Significantly he points to the fact that, although there has been an increasing trend of late (mainly be gravel of improved operating techniques) to get to repair menisci and cruciate ligaments, this has not been accompanied by an apparent reduction in the rate of post-traumatic osteoarthritis. Similarly, arthrosc opic 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 denomination 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 pixilated evidence to support the design fault explanation of the aetiology. There is youthful anecdotal data to suggest that improving the control of the knee may have an impact in reducing the incidence of these injuries.This views back up in a paper by Carafe (10) who looked at improving the proprioceptive and balance mechanisms in footballers over a three season period. They report an 87% decrease in the incidence of injuries to the ACL. It may be significant that they analyze semi- professional and amateur footballers who, presumably, did not train as efficiently of as skillfully as their professional footballer counterparts and therefore there was probably considerable room for improvement.Similarly constructed studies have shown similar pattern of improvement in new-fashioned 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 as well as small to allow a decorous 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 importantly 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 (propriocept ive)training is not nevertheless universally recognised by coaches and trainers as useful tool. As a result, he argues that it is the responsibility of doctors and physiotherapists to unfold 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 inveterate presenting symptom in any sports related health professionals 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 Jumpers 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 influence to try to get resolution of the problem.In con clusion 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 BasketballAs 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 persisten t 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 exhibit 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 however produced any specific evidence that sprains and strains are reduced.duad seen to be more effective than tape in preventing sprains of the ankle (7,8) Bracing has the advantage that it is more delicious 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 tenderness to the skin to exert its protective influence. It can cause skin irritation and has to be reappl ied on virtually every occasion where potential stress can occur.One of the major problems of doing research into ankle injuries is that soft and subjective measurements such as pain and immobility can be easily assessed, but the ankle joint is a very functionally Byzantine structure and quantitative measurements of anything other than flexion/extension or rotation an very difficult. Its therefore inspiriting 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 interest group of completeness and we do not propose to go into any detail about the instrument.There is an excellent word by McKay on ankle injuries in basketball (20) but this is discussed at some length in the section on prophylaxis of injuries.Treatment of injuriesThe treatment of sports related injuries is a vast take and specialism in itself. The sports medicine medical specialist and the physiotherap ist sports specialist are technically knowledgeable volume 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 apothegm of ICE (immobilisation, compression and elevation) (20b) is a useful first-aid mnemonic which will help to minimise injury front 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 papersThe area of dental trauma is highlighted in the analysis by Kujalae t 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 polemical 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 recuperation 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 technique s 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 unmarked on the sports field.There are two recent papers which examine the thorny problem of misfortune 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 go through 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 playedThere are few studies that actually compare the rates and types of injury with actual position played on the court. given(p) 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 strictly 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 posit ion, and court location (this is a reference to the proximity to a hospital). In veritable terms, the players position is of much less importance in predicting injury than many other factorsClinical considerationsThe clinical implications of basketball injury must be viewed in the context of the benefits derived from playing any competitive sport or indeed pursuing any academic 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. all the way, 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, genial interaction, increase in self-confidence and satisfaction in par ticipation 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 by and large could lead to untimely osteoarthritis. Specifically it found that, in the elite global 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 disablement and basketballIt is important not to ignore the fact that basketball is played, not only by able sportsmen but also by those who have a concurrent disability as well. This gro up also presents a professional problem for the physiotherapist as. non only are there the normal considerations for the able 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 Persons Employment execution (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. vigor 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 th at 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 actionsEarlier 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 a t 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. forthcoming?) 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 preexistent injury. It follows that, if thatinjury can be prevented, then the subject is statistically less likelyto suffer a further injury.Common sense is b ehind 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 moInjury Risk in Elite Basketball PlayersInjury Risk in Elite Basketball PlayersThe 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.IntroductionBasketball 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-wi de basisTraining 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 pi ece 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. Its 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 we re 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 totalLower limb Total 56.0 Thigh 2.5 Knee 15.8 Leg 2.0 Ankle 31.4 Foot 4.0 Other 0.4Upper Limb total 19.3 Upper arm + Shoulder 2.6 Forearm and elbow 1.3 Palm + wrist Fingers 11.1 Other 0.4Other 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 1.4There 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 lions 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 modali ties 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 totalSprains +strains 61.3 Knee 12.4 Ankle 29.5Bruises + Wounds 22.2Fractures 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 4.9Dislocations 1.7 Knee 0.5 Shoulder + elbow 0.3 Fingers 0.3 Others 2.2Sprains 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 horrifying 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 appar ent 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 injuriesBruises 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, its 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 BasketballAs 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 in jured 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 e arlier 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 iden tification 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 considerab le 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 s uch 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 professionals 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 Jumpers 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 Basketbal lAs 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 w ith 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 asses sed, 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 injuriesThe 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 papersThe 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-ai d 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.T here 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 playedThere 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 ra ther 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 factorsClinical considerationsThe 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 fou nd 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 significantDisability and basketballIt 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 wi ll 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 Persons Employment Act (1944) was the first majorlegislative landmark in the effective rehabilitation of the disabledperson back into society and other legislation rel ating 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 ex perienced 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 actionsEarlier 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 act ual 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 impro ving the drafting of game rules so that violentinfringements of the rules can be mo