Basketball and the Foot and Ankle

Basketball is a sport that's increasing in popularity both in the US and abroad. New developmental (minor) leagues are forming, and, certainly, at the high school level we see many more athletes participating in the sport. This year alone, over 1.6 million injuries will occur in people playing basketball. These injuries may be either acute or chronic. Proper treatment of both types is important to prevent long-term disability.

Acute injuries are those events that occur traumatically at a specific point in time. Chronic or overuse injuries occur over a much longer period of time and the athlete often cannot point to a direct situation or cause of the problem.

Ankle anatomy
The ankle is made up of 3 main bones; the lower end of the tibia, or shinbone, and the fibula, or outer bone of the ankle, and the talus that lies between the tibia and the fibula. Holding these structures together are the ankle ligaments that connect one bone to another. Holding the shinbone to the talus bone on the inside of the ankle is a very strong tissue called the deltoid ligament. On the outside of the ankle are 2 smaller ligaments holding the fibula to the talus bone, and 1 ligament from the talus to the calcaneus (Fig. 1). Also not to be forgotten are the muscles that surround the ankle that help propel it and allow athletes to run and jump.

Achilles tendinitis
Achilles tendinitis is the most common injury of the foot and ankle. At the point where the calf muscles combine, they form the strong, rope-like Achilles tendon that inserts on the back of the heel bone (Fig. 1). This tendon allows the calf muscles to push the foot and toes downward, allowing a person to run or jump. In running or jumping sports, such as basketball, this tendon can become irritated and cause chronic problems. Repetitive overuse of this tendon can cause the overlying sheath of the tendon to become inflamed. This results in chronic pain and tightness of the tendon, which is Achilles tendinitis.

Achilles tendinitis usually develops slowly, frequently resulting from a change in training, such as adding mileage or hill running. The problem is usually an excessively tight muscle in the Achilles tendon muscle group that causes inflexibility. This causes the tendon to become stretched, which can lead to inflammation and swelling. If the problem persists, it can lead to microtearing or complete tears of the tendon. Symptoms include pain when the muscle is stretched, both during and after an activity, and visible swelling. If symptoms persist, a small scar tissue nodule can form within the tendon and cause severe pain.

Treatment for Achilles tendinitis includes rest until the acute inflammation subsides, ice to the affected area, and anti-inflammatory medications such as ibuprofen. A small heel lift can be used to reduce tension on the Achilles tendon. A stretching and strengthening program of the muscles influencing the Achilles tendon is vital for long-term benefits.

Ankle instability
The ligaments of the ankle undergo a tremendous amount of stress during basketball maneuvers. One of the most common injuries in basketball is the ankle sprain, where the ligaments are stretched or torn after the foot is rolled inward (Fig. 1). Ligaments heal but remain loose after an injury; therefore, multiple sprains can result in chronic ligament laxity. As the ligaments become more and more stretched after an inversion injury, the ankle has a feeling of giving away even with minimal motion. The ankle may be swollen, and the injured person will often say that he or she cannot pivot or twist on the ankle.

Rehabilitation exercises are often used to condition the muscles around the ankle to help maintain stability. The ankle muscles themselves can help make up for the stretched ligaments. A brace can also be placed around the ankle to help support the ligaments if the looseness is not too severe. If these treatments are not effective, surgery may be necessary.

Plantar fasciitis
The plantar fascia is the hammock that connects the bottom of the heel bone to the bottom of the toes. This hammock of fibrous tissue provides structural support for the bottom of the foot. An excessive amount of stress on this area can cause extreme pain at the weakest point of the hammock, where the plantar fascia attaches to the heel bone. This also causes swelling of the hammock, which is known as plantar fasciitis (Fig. 2). Indications include pain with the first few steps after rising from a seated position. Pain seems to quickly subside after movement begins. However, these symptoms may worsen over time and occur for longer periods after rising. Plantar fasciitis is probably the result of inflexibility somewhere else in the foot or ankle. For example, if the Achilles tendon is too tight or inflexible, this force is transmitted to the plantar fascia hammock and scar tissue and inflammation will result. A physical examination reveals tenderness on the bottom of the heel as the examiner pushes on this area. The patient feels shooting pain that sometimes goes down into the toes. In general, the Achilles tendon is tight, and other portions of the foot may prove to be inflexible as well.

Treatment for plantar fasciitis includes a period of rest, inflammatory medication, and an aggressive stretching program to help remove the excessive force placed across the plantar fascia hammock. Once treated, inflammation, swelling, and other symptoms will go away.

Stress fractures
Stress fractures, also called fatigue fractures, can be disabling problems for athletes. Stress fractures in the lower extremities are related to overuse. In the foot and ankle, they most often occur in the distal shinbone, or tibia, or at the base of the fifth metatarsal, or in the lateral (outside) foot bone. A stress fracture is a phenomenon whereby multiple, repeated stresses can easily lead to a fracture. It is important to recognize stress fractures early on. If a stress fracture is missed, it could potentially lead to a complete fracture with devastating consequences.

Symptoms of stress fractures include pain directly over the bony area, such as the shinbone, with swelling and inflammation. X-rays are often negative because the bones have not completely broken. Often, a bone scan or a MRI is required to diagnose these injuries. Once diagnosed, there should be a period of immobilization and no weight should be placed on the injured body part.

Rehabilitation exercises will be required to ensure optimal flexibility in the area. Once symptoms have subsided and once flexibility is again attained, the athlete can generally return to play without difficulty.

Basketball is a demanding sport, but with a good strengthening and flexibility program, most basketball players can continue to play at the level they desire.

Robert J. McAlindon, MD
Auburn, Alabama