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REVIEW ARTICLE
Year : 2019  |  Volume : 19  |  Issue : 3  |  Page : 72-77

Critical review of incidence and etiology of ankle sprain and stress fracture in basketball


Department of Physical Therapy, King Abdulaziz Hospital, Makkah, Kingdom of Saudi Arabia

Date of Submission17-Jun-2020
Date of Decision30-Jul-2020
Date of Acceptance04-Aug-2020
Date of Web Publication21-Aug-2020

Correspondence Address:
Mr. Ahmad Khiyami
Department of Physical Therapy, King Abdulaziz Hospital, Makkah
Kingdom of Saudi Arabia
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DOI: 10.4103/sjsm.sjsm_7_20

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  Abstract 

Basketball is the most engaging game to take place in any community. It involves high-intensity physical activities that require changing direction continuously, along with high-load actions. To make this sport safer, it is essential to understand the causes of injuries during games. Furthermore, understanding the intrinsic, extrinsic, biomechanical, psychological, and physiological risk factors, it is also crucial to be aware of the incidence and prevalence of associated injuries. Such knowledge will facilitate the development of new prevention techniques and methods that will help prevent extensive sports injuries and make sports safer.

Keywords: Ankle sprain, basketball, rule changes, stress fracture


How to cite this article:
Khiyami A. Critical review of incidence and etiology of ankle sprain and stress fracture in basketball. Saudi J Sports Med 2019;19:72-7

How to cite this URL:
Khiyami A. Critical review of incidence and etiology of ankle sprain and stress fracture in basketball. Saudi J Sports Med [serial online] 2019 [cited 2020 Sep 18];19:72-7. Available from: http://www.sjosm.org/text.asp?2019/19/3/72/292948




  Introduction Top


It is essential for people to contribute in sports. One of the most significant benefits of engaging in sports is an improvement to overall health which can diminish the risk of many diseases. Moreover, sports play a crucial role in enhancing human psychology. Sports can also enhance people's quality of life, leading to achievement, success, and self-satisfaction.[1]

Jumping and landing is an essential component of basketball, as players must make multiple shots and use many skills such as layup and jumping shots or guarding. These skills are essential in basketball, yet they raise the risk and incidence of injury. Basketball also depends on high-intensity physical activities that require a continuous change of direction along with high-load actions.[2] During a competition, many contact or noncontact injuries can occur. The study shows the lower-limb injuries during competition sustained (58%–66%).[3]

Ben Abdelkrim et al.[4] illustrated that a basketball player's position might lead to several injuries. There are five positions in basketball which are guard, point guards, power forward, small forward, and centers. These positions can play an important role in terms of leading to different injury types due to different performance and endurance according to the player's position. According to Ben Abdelkrim et al.[4] and Harris and Stone,[5] a forward player position is more likely to suffer from a stress fracture. While the center is more likely to get an ankle sprain, a muscle strain, a fracture, or a hand injury due to a high level of physical activity during the game. The shooting guard is more likely to get an ankle sprain injury due to the high rate of jumping and landing. Considering the player's position in relation to lower-limb injuries is very important in order to prevent injuries and should be studied more.

A study demonstrated that the incidence of overall basketball injuries during one competitive season is 9.8/1,000 h,[6] whereas other studies done in Swedish related to elite basketball showed that the incidence rate of basketball injuries is 2.5 injuries/1000 activity-hours in male and 2.85 injuries/1000 h of activity in female players.[7] Another research illustrated that the basketball injury rate associated with the National Basketball Association (NBA) is 19.3/1000 athlete-exposures and 24.9/1000 athlete-exposures among the Women's NBA; the study had done with 702 NBA athletes and 443 Women's NBA athletes.[8]

Moreover, another study had focused on basketball players' physical activity during games and has shown that the player is required to change direction every 2–3 s and to continuously accelerate and decelerate. This places a massive load on the ankle parts, particularly on ligaments, because of the sudden and quick movements. Indeed, basketball can involve 35–46 jumping and landing activities per game, which is 2–4 times greater than that found in soccer, volleyball, or any other sports.[9],[10],[11],[12]


  Ankle Joint Sprain Top


Ankle injuries incur an annual health-care cost of over $4 billion in the U.S. alone.[13] Lateral ligament injuries are the most common, constituting 7%–10% of all admissions to hospital emergency departments.[14],[15],[16],[17] The incidence of acute ankle sprain of 139 players related to basketball was 6.0/1000 h.[6] Moreover, other researches showed that the incidence of ankle sprains related to basketball in emergency departments in the United States is 41.1% (2.15/1000 person-years).[13] Furthermore, another study prepared in U.S. high schools shows that ligament sprain injuries consist of up to 44% of overall lower-limb injuries.[18] Further, ankle injuries are more potential to occur in females than males.[19],[20] They are also more likely to be recurrent at 73% rather than a new injury.[6],[21] Another study shows that ankle injuries occurred at a rate of 3.85 per 1000 basketball players' participation.[22]

Ligament sprain is divided into three grades of injury: 1 – partial tear, 2 – incomplete tear, and 3 – complete tear.[23] The study showed that inversion injuries constitute about 25% of all musculoskeletal system injuries, around 50% of which are related to sporting activity.[24] The lateral ligament of the ankle is made up of the anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament.[25] One or more ligaments may become injured depending on the force applied resulting in the injury. Moreover, as noted earlier, basketball requires an immense amount of jumping and landing.[10] During games, the player may land badly (inversion of the plantar-flexed foot or eversion), twisting the ankle, either inward or outward causing a severe injury to the ankle joint.[26] McKay et al.[22] showed that 45% of ankle injuries occur during landing.

In fact, inversion with plantar flexion is the most prevalent type of ankle injury. When the load is very high, a tear of the anterior talofibular ligament occurs.[27] It also leads to a tearing of the calcaneofibular ligament. This is because the calcaneofibular ligament is the next ligamentous structure to resist stress: if it tears, this leads to ankle joint instability.[28],[29],[30] The injury rate of lateral ankle sprain in the US college athlete between the years 2009 and 2014 is 11.96 male and 9.50 female/10,000 athlete-exposures.[31] The eversion type of ankle injury (medial ankle sprain) is less frequently seen and constitutes up to 5.1% of all ankle injuries with an incidence rate of 3.5/1000 person,[28] alternatively male athletes having a higher incidence than female athletes in this type.[32]

In addition, acute lateral ankle sprains do not cause any long-term disability according to Hertel[33] but may lead to residual symptoms or joint dysfunction on the part of athletes. However, the incidence of recurrent ankle lateral sprain is more than 40%, and it is a significant cause of chronic ankle instability (CAI).[33] Moreover, as many as 80% of patients with CAI are expected to suffer from osteoarthritis (OA) and, in some cases, require surgical intervention.[34] OA can be prevented by developing a prophylactic program which includes advanced mobilization and strengthening exercises that avoid recurrent injury and enhance joint stability. Herb et al.[30] showed that players with a history of acute ankle sprain are more likely to get CAI and generally depending on landing strategies. However, acute ankle injuries and recurrent ankle instability during functional activities have been related to mechanical and functional impairments. Such impairments constitute limitations and restrictions in sports competition or professional activities which consequently affect a sportsperson's health-related life.[35],[36]

The normal biomechanics of the ankle joint when the foot in a nonweight-bearing position, if the ankle is plantar flexed the foot rotates inward, while rotated outward if the ankle is dorsiflexed. The foot rotated internally, if the ankle is dorsiflexed, and externally if plantar flexed during weight-bearing.[28] Many biomechanical risk factors can lead to ankle injuries including increased ankle plantar flexion, residual ligamentous laxity, cavus foot (high-arched foot), postural sway, impaired balance, center of gravity displacement, loss of the base of support, and increased body mass index.[37],[38],[39],[40] They all can lead to a lateral ankle sprain and increase the rate of reinjury.[41],[42] Moreover, postural balance problems, loss of joint position sense, abnormal range of motion (ROM), and impairment muscle reaction time (either very slow or fast) can lead to muscle time imbalance between the agonist and antagonist, muscle weakness which leads to diminishing support to the ankle joint, abnormal gait pattern, and ankle instability (hypermobility).[37],[39],[41],[42] Furthermore, abnormal ankle and forefoot mechanism, muscle tightness, and poor alignment of the lower limb may lead to ankle injuries.

Bali[43] studied the psychological risk factors related to ankle sprain injuries and found that mental readiness was strongly associated with success in sports, as excessive stress, anxiety, tension, fear of injury, aggression, and negative arousal may dramatically diminish an overall player's performance[43] as well as increase the incidence of ankle sprain injuries. Many studies have also shown that psychological aspects significantly affect the general player's performance after an ankle joint injury, leading to a decline in performance and increased fear of reinjury during competition. Moreover, psychological factors can reduce the mental ability during the competition makes players more susceptible to injury. In addition, seeing an injured colleague may also distract athletes, leading to a decrease in performance and an increased risk that they themselves become injured.[44] There are five stages after injury according to the Kübler-Ross model including isolation or denial, anger, bargaining, depression, and acceptance.[45] If the player fails to overcome any of these phases, this may lead to reduced performance and an increase in the incidence of injury.[44] Many studies showed that psychological factors should be assessed in order to improve the player's performance and reduce the injury incidence. Arousal can be measured by electroencephalogram, electromyograph, heart rate, and blood pressure.[46] Furthermore, anxiety can be measured by sport concussion assessment tool[47] or sport anxiety scale.[48]

Moreover, there are significant demographic and morphological factors that affect and increase the incidence of ankle sprain injuries. These include age (younger athletes more than adult athletes due to laxity), gender (female more than male),[49] previous injuries,[50],[51] and somatotype.

Furthermore, physiological risk factors include muscle fatigue, heart failure, reduced cardiorespiratory endurance, central balance problems, co-ordination disorder, residual ligamentous laxity, decreased muscle power, loss of muscle flexibility, and reduced reaction time of the tibialis anterior and gastrocnemius muscles.[38],[41],[52]

In addition, extrinsic risk factors such as day temperature[53] and the playing field surface,[54] ankle bracing, taping, the intensity of competition, equipment, the time of the game or season, the training level, the level of competition, and player position also are key factors.[38],[55] According to McKay et al.,[22] the ankle injury rate increases 4.9 times if there is a previous history and 2.7 times if the player does not stretch his muscles. In addition, another study shows that shoe design does not increase the incidence of ankle sprain in basketball.[56],[57] Therefore, I think that there needs to be more focus on intrinsic and extrinsic risk factors with regard to ankle injuries in basketball.


  Lower-Limb Stress Fracture Injuries Top


Stress fractures are common overuse injuries in the lower limb that are regularly seen in athletes and elite players. They constitute approximately 10% of all overuse injuries in basketball.[58] Another study shows that stress fractures account for 0.7%–20% of all sports injuries in a medical clinic.[59] However, the prevalence may be higher than 15% in a sport such as running.[60] Another study has shown that stress fractures account for up to 7% of all sports injuries[61] and mostly affect larger bones.[62] The familiar site of a stress fracture is in the lower extremities, and it affects women more than men.[63],[64] A stress fracture affects such lower-limb bones as the tibia (34%), distal fibula (24%), metatarsals (18%), the femoral neck and shaft (14%), and the pelvis (6%).[65] The injury mechanism is that the bones fail to adjust to the continuous mechanical load and the summation of repetitive forces during physical activity, and there is an insufficient recovery time for remodeling. Microdamage then accumulates and propagates into a stress fracture.[66],[67],[68] Stress fracture complications include pain, swelling, and missed playing time, which lead to decreased player performance. Surgical intervention results in improved performance metrics for players compared to players whose injuries are treated nonoperatively.[13],[68]

The physiological risk factors of stress fracture include muscle fatigue,[62] a deficiency of Vitamin K which can reduce the healing process,[69] lower-limb joint OA (knee and ankle),[70] age,[71] sex (female more than male),[72] hormonal factors (like postmenopausal women),[73] footwear[74] and low bone density,[73] training parameters, muscle imbalance, restricted joint ROM, and lack of flexibility, whereas biomechanical risk factors include poor skeletal alignment,[75] hyperpronation of the ankle,[58] a high longitudinal arch of the foot,[76] various alignments in the ankle and forefoot,[75] foot deformity, body mass index, central of gravity displacement, and a high degree of external rotation of the hip.[77]

Furthermore, psychological risk factors include depression which can reduce the efficiency of the healing process,[78] anger and anxiety can directly lead to a stress fracture. These factors reduce the athlete's performance dramatically.[79] In addition, there are many extrinsic risk factors which can increase the prevalence of stress fracture including the level of competition, player position, time of the game or season and the training, and play surface.


  Rule Changes Top


Recently, basketball injuries have been reduced as a result of rules being continually changed to make basketball safer and more secure. Given that different age groups participate in this game, the rules should also be designed to protect younger players, especially in schools.

In addition, it has been proved that applying strict adherence to the rules in basketball will prevent injuries. Indeed, the rate of basketball injuries has significantly decreased throughout the world. As noted previously, most basketball injuries occur in the ankle joint. However, there is inadequate research on the relationship between ankle injuries and rule changes.

In basketball, the rules have changed continuously. For example, injuries such as concussion and lower- and upper-limb injuries can be prevented by prohibiting elbow swinging, blocking, and charging, and there has also been the introduction of the 30-s rule.[19] Nowadays, the 30-s rule has changed to 24 s. Furthermore, jewelry and metal items are forbidden. In order to prevent ankle injuries, each player should wear suitable shoes. In addition, using a leg block is forbidden, reducing illegal activity.[80] These new rules should dramatically reduce the injury rate.[81]

Furthermore, there are restricted rule modifications aimed at avoiding injuries such as each player being allowed five fouls. If exceeded, the player will be sent off. In addition, a hand on the dribbler and excessive contact are forbidden. Before rules modifications, these actions were permitted.[82]


  Conclusion Top


In this critical review, we have highlighted the limitations and shortfalls in the current literature which explore how risk factors are related to injuries. We found that studies focusing on risk factors do not clarify the connection between the injury and its risk factors. Furthermore, studies have been carried out in different areas of the world, such as in the USA, Japan, and the UK, without referencing the criteria in other countries. Moreover, the incidence and prevalence rates in some of the studies are out of date (too old) because many rules have recently been changed. I believe that research can encourage changes to rules once the evidence is strong enough.

Moreover, many studies claim that understanding the psychology of players can prevent many injuries. This has been overlooked in Saudi Arabia because of inadequate studies yet may help to reduce treatment cost and even save players' lives. Furthermore, some research criteria in one country do not appropriate in many other countries such as fitness level and the injury rate, that the reason for taking the control group. However, we think that we can reduce the incidence of many injuries by developing and inventing new prophylactic programs. As things stand, there are limitations and gaps in existing prophylactic programs which must be addressed to prevent recurrent injury.

Addressing risk factors is the most suitable and effective way to envisage and predict injuries. We may prevent many sports injuries once we understand the possible risk factors. Among the physiological, psychological, and biomechanical risk factors associated with an ankle sprain that are mentioned above, we believe that the most important factors that can lead to ankle sprain are postural imbalance, joint position sense, ankle dorsiflexion ROM, wrong muscular reaction time, ankle instability, and co-ordination system disorder. Moreover, we suppose that the most significant factor is that of the previous injury, while the field surface and player's position are the most critical extrinsic risk factors. Among the psychological risk factor, anxiety, depression, previous injury, and anger are the most significant factors, whereas the significant factors that lead to stress fracture are joint OA, training parameters, foot deformity and alignment, shifting of COG, depression, and anger.

In conclusion, there needs to be a greater focus on the extrinsic risk factors in basketball, as well as on prophylactic programs aimed at inventing new equipment that makes basketball safe for both elite players and young players.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  In this article
Abstract
Introduction
Ankle Joint Sprain
Lower-Limb Stres...
Rule Changes
Conclusion
References

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